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FOR OFFICE USE: - ------------------------------------------------------- - APPLICATION FOR SANITATION PERMIT Permit No __._--_-.- __.- --------------------------------------------------------- (Complete in Duplicate) w ------------------------- This Permit Expires 1 Year From Date Issued Date Issued ____.____._ ,li�_. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. / ,�JOB ADDRESS AND LOCATION... T. C? 7 Zi I-TPR fl -�_ __ ---------- a n. Owner's Name. --------------------------------------------------------- - -- -- Phone-----------•--------------- Address----------------- -------13CPK--------Z '?--------MT-C = Contractor's Name---------- tr ---------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence e— Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --/----.Number of bedrooms _� Number of baths -1----- Lot size ____19 _------------------------------------- Water Supply: Public system ❑ Community system ❑ Private Imo' 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 New Construction: Yes ❑ No 2�' FHA/VA: Yes ❑ No [�~ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well Distance from foundation...................Materiall__ ..._----.-----..-__-----___. C)KDST►A(0__ No. of compartments--------------------- - - Size-------------------------- -----Liquid depth--------------------------Capacity------_-------------- Disposal Field: Distance from nearest well-__5D-----Distance from foundation------(0.......Distance to nearest lot line---- ---�-._____- Number of lines------------- � � i1----..Total length----------_-�� " ---------------------Length of each line------ ------,_--- Width of trench---___3-4,,_--- --------------� Type of filter material---- C�.CJ .___Depth of filter material------ ---------------------- Seepage Pit: Distance to nearest well--------------_------Distance from foundation--------------------Distance to nearest lot line-_-__--._----- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------. Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation_----_------___.___.Lining material-----------------------------------_- ❑ Size: Diameter----- ---------- -------------------Depth----------------------------------------------------Liquid Capacity- - ------------------------gals.-S Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----_----------_----------------._._---�0 .5 ❑ Distance to nearest lot line_----------------------------------------------------•---------------------------------- ---------------------------------------- Remodeling and/or repairing {describe):-- ------ - ----- --------------- ----- - ----- •----• ----------------------------------------- -------------------------------------------------------C -----------••----•--------•--------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ----------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- -- ------------------------------------------------------------------------••--------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Iws, a rules nd re ulatio s of the San Joaquin Local Health District. (Signed)- ------------ -- ---------------------------- -------- - --------------------------------------------------_----------------•-------------------(Owner and/or Contractor) B (Title)_ v Y• _......-----•---•---•,----�------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). p FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ----------------------------- ----------------•----------------------- DATE---- -. -7------- REVIEWEDBY---- - ------ -- ------------------------------------------------------------------ DATE------------ ------- -------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------ --------------- ----------- -------------------------- Alterationsand/or recommendations----------------------------------- -------- --------------------------------------------•-----•-------------------------------•------------------------------- ----------------------------•-------------------- --------------------- - ------ ----------------------- ------------------------------------------------------------------ ----------------------------------------------- ----------------------------------- --------------------------------------------------------------------------------- -----------------•------------------------------------------------•----------------------------------•--•--------•---------------------------------------------------------------------- ----- •-------------------------------------------------- - - --- - -------------------- - -------------- ----------------------- ------------------------------------ - ---------------------------------- -------..... ------------------ FINAL INSPECTl.QN - 7 Date - _-�----------- --- --------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California F.p.co. a