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. .. ,F'OROFFICE USE: lI t� ____..__ -_-_-r__._._,.__-______ ___________________.__.__--__. APPLICATION FOR-SANITATION PERMIT Permit No, ------------------- --- -------------------------------- [Complete in Duplicate] ------------------------------- This Permit Expires 1 Year From Date Issued Date Issued l0_'` _ �� 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------ r_________.__r - _- Owner's Name!",? ��.�------------------------------ ---------------------- ----------------------------------------- Phone------------------------------------ Address { -------•-------------------•-•----------•-•----------------------------------------------------------------------------- Contractor's Name------- 'J ------------- ---------------------------------------••-----•------ ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____I-__ Number of bedrooms __3_ Number of baths _j____ Lot size --- _________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -(Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[B—Hardpan ❑ Previous Application Made: (If yes,date-----------_--------) No New Construction: Yes ❑ No ?Et'� FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septicnk- Distance from nearest well----------------- from foundation___________________.Material-___._.______-_ _ ____________-_----_...______- `�J No. _ _ _ _of compartments------ -------------------Size------------------------------_Liquid depth------------ -------- ---Capacity----------------------- ` Disposal Fie Distance from nearest well__`.'_r'___.._Distance from foundation__J0_`.._______.Distance to nearest lot line_�______ Number of lines-1------------------------------Length of each line---A0-----------------.Width of --- -------------------- Type of filter material' &_(_o'j�----Depth of filter material---/$'_----------Total length-------._ p-`_________________-._ r Seepage Pit: Distance to nearest well-------_•- ____-_-Distance from foundation___LS?_._._..__.Distance to nearest lo} -- Number of pits_.-----I-------------Lining material.-_'_/?'_O_G�t..Size: Diameter___-33.7_------Depth._._ ,"__�_._.-_-.-- Cesspool: Distance from nearest well-----------------Distance from foundation...._._.__..____-_.Lining material__._...____-__-.-.____.___-__•-.__. ❑ Size: Diameter------------------------------ -- ----Depth-------------------------------------- -- ----------Liquid Capacity----------------------------gals. Privy: Distance from nearest we11----------------___------------------------------Distance from nearest building-___.____.-_--.----_____________.__.-_. ❑ Distance to nearest lot line---- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certif2�7 e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laesand regulations of the S n Joaquin Local Health District. (Si ned __-_..__--___-(Owner and/or Contractor) 9 ) . ----------- . ----- ------ 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----- REVIEWEDBY-------------------------------------- - - --------------- ----------------- ------- -------------------- DATE---------------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE----- Alterations and/or recommendations----------- ------- ---------------------------------•----••-----------------------------------•-•- ---------- -- ------------------------------------------- •------------ ------------------ -- --------------------------------- ------------------------------------------------------------------------- --------- ------------------------------------------------------------------------------------ --------------------------------------------------------------(------------------------------------------------------------------------- FINAL INSPECTION BY:. ------- M ------------------- Date-------Y.. ../....-/ - ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Maxellon Ave. 300 West Oak Street 724 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.