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FOR OFFICE USE: Oo ! __051-3 APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ----------------------------------- -- ---- -- ------- (Complete in Duplicate) - -..__.-._ 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 clescrilled. This application is made in compliance with County Ordinance No. 54�9.` --- JOB ADDRESS AND LOCATION--- _ --------- .... `1 -------- --------------- Owner's Name-------- ----- X-091" --- Phone--------------------------- Address------------ m�-------- ----44k--f---------- Contractor's Name__eo!:A r------------------------------------------------------------------------- -------------------------------------------- Phone-----•----•-----•-•---------------- Installation will serve: Residence * Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A----- Number of bedrooms -------- Number of baths Lot size ___/- _____ __________________ Water Supply: Public system F] Community system ❑ Private g& Depth to Water Table 4_0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay L� Adobe ❑ Hardpan* Previous Application Made: (If yes,date______-------_-----) No ❑ New Construction: Yes ❑ No ❑ 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-------------------.Material _____.___..___..___._.____._____...__._.__..__- [] No. of compartments--------•- --------- -----Size--------------------------------Liquid depth------------ - - ---------Capacity----------------------- Disposal Field: Distance from nearest well.-_-------------Distance from foundation--------------------Distance to nearest lot line___________._____ ❑ Number of lines-----------------------------------Length of each line----------------------------..Width of trench------------------------------------ Type of filter material-------------------------Depth of filter material-----------------------Total length-----------_----_____________________.__-. Seepage Pit: Distance to nearest well-JOT-----------Distance f om foundation--- istance to nearest lot line__l�. _...___ 4 Number of pits.-..-/--------------Lining materiaLU�___Size: Diameter---A 43- ------Dept h...62.IS."?------- ---__..__ 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 lire----------------------------------------------- ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--- ,��l - --- Z ..t - !V,�------------------------------------------------_ ---------------------------•---------------------------------------------------------------------------------- ----------------------------------------------------------•.------------•---------------------------------------------•----------------------------------------------------------- -- 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, a rules andationthe San Joaquin Local Health District. (Signed] ------------------- - (Owner and/or Contractor) BY :. =" -=--=---=-----------------------------------------------(Title)------- ---------=--------- Y = ---.--... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). N FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY-- * +�„� ------------- -------------------------------------------- DATE_-J-,_.� ``--------------------------- W REVIEWEDBY--------------------- ------------------ -- ----------------------------------------------------------- ------------------- DATE------- ------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE---------------------------- ----------------- -------- Alterations and/or recommendations:--------------------------------------------- -----------------------------------------------•------------------------------'------------•---------------- If ------------------- ------------------------------------------------ ----------------------------------------------------------------- ------ ---------------------------------------I---------------------------------- FINAL INSPECTION BY: Date ' � SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi, California rw Manteca,California Tracy, California F.P.C C.