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FOR OFFICE USE: �* APPLICATIONS FOR.SANITATION PERMIT Permit No. - -------------------------------------------------------- ---------- ----------------- ------------- ------------- { (Complete in Duplicate) Date Issued -------------- This Permit Ex ires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance`�1 with County Ordinance No. 549. --5-4--9--. JOB ADDRESS AND LOCATION -- -------�-- ----------------- ---------------- - ----------------------------- Owner's ! Name--- - ---- - ----- - Phone------------------------------------ ----- ----- Address--------- ----------- --------- -------------------------------------------- ------- ------------------------------...-- ------•-•• `j141 ----------------------------------- Phoney�4 _.Contractor's Name_______ Installation will serve: Residence )] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Nurhber of living units: ________ Number of bedrooms ________ Number of baths/_-_4 k t size __.__ --- ----------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table ' U ft. Character of soil to a depth of 3 feet: a Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [r Hardpan ❑ Previous Application Made: {If yes,Idate-___.__---------__-I No 2"New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ S 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ep is Tank: Distance from nearest well_________________Distance from foundation__-______________--Material-____--______-_-__--_____-____.---_---____-___-_-- No. of compartments--------------------------Size--------------------- ------Liquid depth---------- ---- - --------Capacity--------------------_ N< qDispose Field: Distance from nearestwelll!'aX�-:Distance from foundation_1CJ____-____.Distance to nearest let line___ Number of lines______ ___________ _ Length of each ---------Width of trench-----.-._`f_,_��_____-__---_____-_ Type of filter material-__S_`LT_oc ____Depth of filter material__. __-_-____.Total length______-�d__�_____________-_____-_ Seepage Pit: ; . Distance to nearest wellI 2i_Q—__Distance, from f undation___L�---------Distance to nearest lot line___3 __--_- Number of pits-__ -_----__--Lining material_ --Size: Diameter__--.7 -19 _ -____Deptn_.__-.G S______________ Cesspool: Distance from nearest well___._!______---Distance from foundation--------------------Lining material__._.___________----_____________.._. ❑ Size: Diameter-I------------------- ---------------Depth-------------- --------------- ----- ---------------Liquid Capacity--------------------------•-gals. t I Distance from nearest building � Privy: � Distance from nearest well. ----- -=------- - ----- ---- ---- - ------------ -------------------------------------- El -------- -- ------.. ❑ Distance to nearest lot line--.--- -------------- ----------------------------------------------- --------------- ---------- - Remodeling and/or repairing (describe}---------- - --------------------------------------------------------------------------------------------------------------------------------------- ---- ;t --------- ---••------------------- ---•--------------------------------------------------------------------------•----------- t _______ 1 ---------------------------- ---------------------•-------------------------- ----- -- - - - - - - - ----------------------------------------------- ----------------- --------------------------- ----- ------ ---------- 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 rules and regulations of the San Joaquin Local Health District. (Signed)-----(& = ---- ner and/or Contractor) ----- -- - - - --- . w Sy:------_------------------- (Title) - -------- -- (Plot plan, showing size of lot, location of system in relay n to wells, buildings, etc., can be placed on reverse side). ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE�BY_ ------------------ DATE------- - -- (---------------------------------- --- ---------------------------- REVIEWED BY---------------------------- - - - --------------------------- ------------------------------------- DATE - - ---------------- --- - IIBUILDING PERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- Alterations and/or recommendations------- --------- --------•------- ----------------------------•------------------------------------------------------------- 4-4��:�::::: ::-�^---- --- -::-------- - ---- ----- --------------------::: ---- ---------------- --------------------- ----------------------------------------------- --- - --------------------- - ---------------------------- FINAL INSPECTION BY:.... � -------------------------- ----- Date---------------- ---- ------- - - - - ---- -- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. s 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 4 - r'.P.C a.