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FOROFFICE USE: _------- 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 an ,Qst.a I the work arei.�des�c.�ib This application is made in compliance with County Ordinance No. 549. /� � JOB ADDRESS A LOCATION 1c---- _ �. - lie(--- ---- q Owner's Name.- -w-- - -- ---------------------------------• -------------- Phone - - Address------------ ., - - r r Contractor's Name---- a.Qr ---• ------- ---- ----- Phone..-------- ----------- Installation will serve: Residence 9/Apartm nt House ❑ Commercial ❑ Trailer Court I] Motel ❑ Other El Number of living units: _..f- Number of bedrooms . _ Number of baths _y. Lot size _.... 'fir L'� � --------------------_-- 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 L] Clay Loam E] Clay [Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date--------------------1 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.) f r Septic nk: Distance from nearest well__.____..Distance from foundation..._.. �_.......Material................................................. No. of com artments--ul------------ -- �� p ...Size.r�..1:.�a...�i`Sf_Liquid depth....�f....._.._______Capacity��_0._ ..-__ Dispos Field: Distance from nearest well.--- Distance from foundation----.r!fd_.l_-....Distance to nearest lot Iine6-- -------- Number of lines_____________� ---------------Length of each line_ �a - -- 1-'------- - --- - -Width of trench.------._-_------------------------- Type of filter material-----*5_v_iZa------Depth of filter material____. __Total length--------lPL.m_Q--------------------- Seep e Pit: Distance to nearest well------Jd_4./-__Distance from foundation------f-.19 r-....Distance to nearest lot line..v-..-----.-. Number of pits._.-.....�--_-_.._Lining material-------..SS-�-_._-.c-Size: Diameter-------- � --- ....Depth.2-S/-------------------- - 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-............-------.--_-___.__._..-._.. A ❑ Distance to nearest lot line--- ------------------------------ ---- ------------------------------- ------- -------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------- ----------------------------------------------------------•-------------------------------------------------------- ... -----------•--------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------- { ------------------------------------- --------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------- -- - - - ----- . ------- --------- --------- ----------------'firer and/or Contractor) By:---- f-------- ---- ----- --------�--------------------------------------------- --------(Title)---------- ---- -------------- --------------.....------------- (Plot plan, showing size of lot, loca+ion of sy em in r ation to welts, buildings, etc., can be placed on reverse side). �! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY d'.• DATE_.�2: .s3.� .`�" REVIEWEDBY------------------------- ---------------------------------------- - ------ - --------------------------------------------- DATE------------ --------------------------------- BUILDING PERMIT ISSUED--------------------- ----------- ------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------- ---- ------------------------------------------------------•--------------------------------------------------------------------------- --------------------------------------------------------------- - ----- ------------------------------------------------------------------------------- -------------------------------------------------------- -----•-- ----------------- ------------- -------- ------- ------------------------------------ --------------------------------------------- -----------------------------•---------------------------------- 1------ - - -..------ - ----------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------ ----------- --------- FINAL INSPECTION BY:�!�� - s* �" _----------- Date-�? z `� +F".......................... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street rn Stockton,California Lodi,California Manteca,California Tracy,California `