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FOR OFFICE USE: �? APPLICATION FOR SANITATION PERMIT Permit No. ----------- 1... �..�.... ------------------------------------------- ----------- (Complete in Duplicate) it 7� This Permit Expires 1 Year From Date Issued Date issued ___. _�.___ �_� 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 Ordin nce No. 549. JOB ADDRESS AND LOCATION h J�J 1l- ----- -- ------------ i! ; Owner's Na - _------- ----------------------------------------------------- - ------- --------- - --------- ----- Phone A �' Address.......m .................. ------------------------------ ------------------------------------------ Contractor's Name-- - %�t#1 `Pt r --•---------- -------------------- Phone----------------------------------- Installation ----------------------- - -Installation will serve: Residence [T' Apa tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ q ,[ 1 Number of living units: ---I___ Number of bedrooms$_- Number-of baths __{___ Lot size __ _D>r___f P_______________________________ 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 [5—Hardpan ❑ Previous Application Made: (If yes,dote--------------------I No New Construction: Yes ❑ No -E FHA/VA: Yes ❑ No U5__ e TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septi Tan . Distance from' nearest well-----------------Distance from foundation--------------------Material-.---------------------------------------..--.__. / No. of comp*rtments--------------------------Size--------------------------------Liquid depth-------------- -----------Capacity-------------- Dispos I Fiekl: Distance from: nearestwell---------------_.Distance from foundation--------------------..Distance to nearest lot line----------------- Number of liries Length of each line Width of trench------------------------------------ Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------- Seepage Pit: Distance to nearest well-.--` -------_-.Distance from foundation_! __ ---.Distance to nearest lot line-A ...... t G_. Nur,nber of pits----#f ----------Lining material--: t?_r:12-------Size: ---------------- V% Cesspool: Distance from nearest well-----------------Distance from foundation-- ..-_----.Lining material------------------------ --_----.-_. ❑ Size: Diameter-------------------------- -----------Depth---------•------------------------------------------Liquid Capacity----------------------------gals.Z Privy: DistanceDistancero n a nearest well----------------------------- - ------------ ------Distance from nearest building------------------------------------------ ,to nearest lot line----------------------------------------------------------- pe ----------=------------------------------------------------------------------- R modeling and/or repa�ri 9 (deseribe]--- ---- ---------------------------------------------------------------- --------- ----------•---------------- - - • tr ------ --------------------------------------- --------------- -------------------------------------- -------------------•-------------------------------------------------------------- --------------- I hereby certify that I have`prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rulesand regulations of the San Joaquin Local Health District. (Signed) ---------- -----------„ -------------------(Owner and/or Contractork r rale------------- Br:-------•-- • -•----• { 1 (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc., can be placed on reverse side). �F k .4 FOR DEPARTMENT USE ONLY IV APPLICATION ACCEPTED BY-----f------------- ------- ----•• . -----•---------------------- DATE.......... ---,/ - ----------------------- REVIEWEDBY-------------------------- ---------------- -------- ------------------------------------------------------------- DATE---------- ------ ----------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------• - Aiterafions and/or recommendations:-_.---.7-_- -_ -iFt ---_-__--.- 'L '1 ---'`. 'P ��-1% ---- -c'-----"--- = 'z�y'`' -`- `=------'t, - '�i r � ------------------------01 '�' ` - `' ' -- `� ---------------•--------------------• -------- -------------------------------- - ----------- --•- ------ -------- - ------ -------- - ----- - -------------------------------------------------------------------------------------------------------------------------- ----- -------- ----------------------- ------------- --------------------• ---- ------------------- --------- •--------- ------------------------------------------------ ------ --------------------- FINALINSPECTION BY--------------- ------- ---------- ---------------------- Date-------------- ------- --------------------- --------------- ---- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.