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FOR OFFICE USE: J --- ------------------------- --------------------- ------------------_-.-__-______ APPLICATION FOR SANITATION PERMIT Permit No. .. --------------------------------------------------------- (Complete in Duplicate) qq Date Issued ________________________________________________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct and install the work herein described. This application is in compliance with County Ordinance No. 549. f 173-200-17 JOB ADDRESS AND LO ATION JQ =3„ '17--`1-------------- --- ---------- Owner's Nam 1 ------------••-•-•---•--------------------------------- -------'-'-'-'-- ------------ --- -- Phone Address ---- �. -----------•------ ----------------7------�---------------------------------------------------------------------•------------------------ Contractor's Name-,, xF -------------------------------------------------- ------ Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: J---- Number of bedrooms ---3- Number of baths _1_____ Lot size ----/ 2' _______________________-_____.__.___ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No �r New Construction: Yes ❑ No �FHA/VA: Yes ❑ No 21-' 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep di Distance from nearest well_________________Distance from foundation-------------------Material____-_.}_ ___-_.._..____.___________..._____-___. No. of compartments-------------- ----------Size------------------ -------------Liquid depth----------------------- Capacity------ ---------------- Disposal Fiel :I Distance from nearest well. .t2 Q. .__Distance from foundation-__1 --------Distance to nearest lot line`s-._f______ ❑ 6V 1I Number of lines-----------i----------------------Length of each line_A9Q_.e----------------.Width of trench___-?�-11- ------------------- Type of filter material_7/- 04r,"_.___-__-Depth of filter material_._.1,r..__..______Total length___- /at3'__.____________________ CIP Seepage Pit: Distance to nearest well-----___---------__---Distance from foundation------------------- Distance to nearest lot line_____.___._______ ❑ Number of pits-----.-.--.----------Lining material-----------------------Size: Diameter.----------------------Depth---------- ---------------------- Cesspool: --- ------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________________________________ ❑ Size: Diameter------ -------------------------------Depth----------- ----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------_------------------------------________Distance from nearest building------.._.___._____-__--_-___..__..____- ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------- ---------------------- I--------------------------------------------------------------------------------------------------------------------- I I. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- I ----------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. C I —It -_ a (Signed)------------------------ =z._________-_-'- - (Owner and/or Contractor) By: ---------------------------------------------- --------------------------------------------(Title)- ----- ----------------------' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------------------------------------- DATE__�9 _.�� ----------_-------- --------------------- - ------------------------------ REVIEWEDBY------------------------ -- ---- ----------- ---------------------------------------------------- DATE-------------------------------------------- BUILDING PERMIT ISSUED------------------ ;--------------------------------------------------- ------ DATE------------------------------ ----- Alterations ---Alterations and/or recommendations:-- --------------------- '-' ------- ------------------------------------------------------------------------------------- ------------------------ -------------------------------------------------------- ------------- --------------------------------------------------------------------------------- ----------------------------------------------------------- ------ - FINAL INSPECTION BY:..-,— 1 ------------------- ---- Date--'-------` Z 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,Caiifornid Lodi,California Manteca,California Tracy,California F.P.CO.