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FOR OFFICE USE: -------------------- ---------- ------ APPLICATION FOR SANITATION PERMIT Permit No. .�` - ------------------------- ---------- -------------------- (Complete in Duplicate) - This Permit Expires i 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 Ordinance No. 549. JOB ADDRESS AND LOCATION- ------------------� --------------------------- vx� JOB _�*_ �. ----- Owner's Name------------------------- ---- --- ~--- -.- -�._ - - Phone-------------- ------------ Address----------------------------- ------------- Contractor's Name___ _ --- L / Installation will serve: Residence ❑ Apartment House ❑ Commercial El Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _______ Number of bedrooms -------- Number of baths -------- Lot size ______________________________-_______________----__.____._ 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 ❑ Hardpan ❑ Previous Application Made: (if yes,date....................I 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.) 11 Septic Tank: Distance from nearest well--_-_'�VIfDistance from foundation------L_11�--------Material No. of compartments..._.____.---_-----Size-----�__X_Ar----x---Y_Liquid depth----------V4 ---- ---Capacity----- G'U ' Disposal Field: Distance from nearest well-__ _._f_Distance from foundation_10---_-----.Distance to nearest lot line_________. Number of lines________________I__....___-_.._ ._Length of each line-.____�.0�_ _f__.Width of trench_____.-_�.�. ___._________._ Type of filter material-___ _. __t. Depth of filter material___L 9_____1.__._Total length_.-_-__-_/Q___________________________ Seepage Pit: Distance to nearest well..._.... 10__�__Distance from foundation______ 0____-_- Distance to nearest lot line_` ____.___._ �( Number of pits.-_.___..1...........Lining material___,44s.� Size: Diameter------�_----------Dept h___----- ------- Cesspool: _.____ C_ esspool: Distance from nearest well-----------------Distance from foundation....----------------Lining material-------------------------------------- F1 Size: Diameter--------------------------------------Depth---------- ----------------- ---- - ----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------___-------___..Distance from nearest building------------------------------------------ ElDistance to nearest lot line---------------------------------------------- ----------------------- -------------------------------------------------------------------- Remodeling and/or repairing (describ �: - • _--/��------ ------. --------- % ------ -------- � � ------.--- --- -_._ li ------------------- ------ -------------------------- --------------- •---------------------------------------------------------------------------------------------------------------- I hereby c ti A I have repar is ap licatio that the work will be done in accordance with San Joaquin County ordinances, S te, aws, nd rul a atPons f 0 uin local Health District. i (Signed)----- ---- -- ---- ---- ----- --- --- ------ ---- - -------- ----- ----------------- --- --------------------------------- - (Owner and/or Contractor) �B ------------------------------------------------------------------------------------------ ----------------------------------- (Title)- ------ --------------- - - --- - (Plot pl n, 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------------------------------- C DATE-------------j-_-J ---J.- .REVIEWED BY ------------------- ------------ DATE----------- .............. BUILDING PERMIT ISSUED---------------------------------- ------------- --------------._ DATE-------------------------- -------- ---------------- ----- - -- ------- - -- - - - ---------- -- --------------- -- --- -- ------------------- Alterafions and/or recommendations:_.___.. ____.. ------------------•--------------------------------------------------- 1 , ---■-------------- ------- ---------------------------------------- ---------------- ---------------- p-- ----------------- --------------------------- - - -------- - '� L FINAL INSPECTION BY:-,-- Date_ :.. Date_______________rya_ __` _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haieltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C. 3`.�