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FOR OFFICE USE: �- --------------- -- ------------------------------ -- --- APPLICATION FOR SANITATION PERMIT Permit No. �. ----------- ------ ---------------------------------- -- (Complete in Duplicate) ------------------- --- This Permit Expires 1 Year From Date Issued Date issued Application is hereby made tar the San Joaquin Local Health District for a permit to construct and install jbe work herein described. This application is made in compliance with County Ordinance No. 549. . - JOB ADDRESS AND LOC ON_/Av/----� j� � -- --- --- ----- - `� Owner's Name- 2, c� -- ------ Phone-------------------- - Address._. - ------- Contractor's Name-----.,--- ame..._.. _ L � --------------------------- --------------------------------------------- Phone----------------------------------- Installation will serve: Residence ®-OA-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ..- Number of bedrooms P-.. Number of baths ..1._ Lot size -.,----------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 947 ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay [] Adobe ❑ Hardpan ❑ Previous Application Made: Ilf yes,date__----------- ----__I No [L]-`�New..Construction: Yes g?"No ❑ FHA/VA: Yes [P— 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_-r .- .-__.Distance from foundation---149-----._Mate;ial--�moi ------------------e. No. of compartments--_.�------------------Size�1�--t -��0------..Liquid depth---}'P�--_----------Capacity-.494 d--- � s Disposal Field: Distance from nearest wel!_��-------Distance from foundation./1�..-...._-.Distance to nearest lot Iinelf......_.... / o ®� Number of lines---- ----------/---- -------- •ength of each line-ft?-�----------�-----.-.Width of firench_.r2......�:--•------------------ Type of filter motorial �,4epth of filter material.. --- Total length--/14Q Seepage Pit: Distance to nearest well .....................Distance from foundation--------------------Distance to nearest lot line----------------- El Number of- pits---------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-------------- -.Distance from foundation.___----_----------Lining material-------------------------------------- ElSize: Diameter--------------------------------------Depth----------------------------------------------------Liquid ,Capacity--- ------------------------gals. Privy: Distance from nearest well------ -------------------------------------------Distance from nearest building----_...._------------....._._..___.__..~ ❑ Distance to nearest lot line ------------------ -------------------------------------- Remodeling ------------------------------------Remodelin and/or repairing describe :.. ---•-•-----------------•------------------------------------ . - --------------------------------------------------------------------------------- ---------------------------------------------------- ------------------- ---------------- ------ ----- -- ----------------------------------------------------------------------------------------------------------------------------------------- - - - --- i + I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ;M. ordinances, State laws, and rules a regulations of the San Joaquin Local Health District. F _..._..... or Contractor (Signed) -- ------. - --- ---- --------- -- ----- - --------------------------------------------- -- --- ----- ------------ITitle) v`-. ---------- (Plot plan, showing size of lot, location of system in re on to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- ----- ---------------------------------------------------------------- DATE-------------------- - REVIEWED BY-------------------------- ------ ----------- ----------------- ------------ - -------------------------- ------------------ DATE--- � k BUILDING PERMIT ISSUED-------------------------------------- ---..---- - -•--- ----n------:----- ------- - - .. DATE------ �-----;�----- -� --- - -'-- -- € � -------- 4 Alterations and/or recommendations:_-_-- - - - CCC --//- --- ----- - ----_ -------- - 6� -------------- ----------------------------------------------•--------------- ------- ! -----------------------`— 1 ... . ----------------------- - -------------------------------------------- ----------------------------------------------------------------------------- ----------------------------- --------------`------.------------------------------------_------_.----------------- FINAL INSPECTION BY-------------- ----- --------- - Date--------------------- `/ r SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1401 E.Hazollon.Ave. 300 West Oak Street _ 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ` Manteca,California Tracy,California F.RCO. j f