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FOR OFFICE USE: ---- --------------------------- APPLICATION FOR SANITATION PERMIT ---- ------------------------------ -------------- Permit No. _ _- -- 'f-•- ----------------- (Complete in Duplicafe) Date Issued _ -` -=-- -� This Permit Expires 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. This application is made in compliance'with County Ordinance No. 549. s } JOB ADDRESS AND OCATION----t'--_---- ._.1 +" ------- Owner s Name------- ----------- Phone------------------------------ ---------- Address----_------------ �-��- ,�-� •-------- -------------------•------------- Contractor's Name_ �- Phone------- ••------------- . ---- ----- Instaliation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/_ Number of bedrooms _3__ Number baths _/_._- Lot size __. - -------------------------- Water Supply: Public system [:1 Community system ❑ Private 2Dpth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel F1Sandy Loam Clay Loam ❑ Clay ❑ Adobe [:] Hardpan ❑ Previous Application Made: llf yes,date--------------------I No F1New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ t 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 compart4hfs---------- --------- Size--------------------------------liquid depth -------------------Capacity a. I i Dispos ield: Distance from nearest well.._.�J......Distance from foundation __11.9-----____.Distance to nearest lot Number of lines-_i------1--___ - Length of each line_____ ----------------Width of french.__-_� _-__----.._.---- v Type of filter material_---_4`� p De th of filter material____�_�_��-------.Total length-------- •.a_________________._____.. r st well.___.-,-.____.__.____pistance from foundation___________________Distance to nearest lot line-------------- Seepage Pit: Distance to nea ----Size: Diameter.---------------- Depth--------------------------------- ❑ Number of pits.___------------------ material----------------------- - -- I Cesspool: Distance from nearest well__._________..__Distance from foundation....................Lining material-._.-__------.--__-.--.-._.,___--.-__. ❑ Size: Diameter--- ------------------------------Depth Liquid Capacity gals. ' I Privy: Distance from nearest well-----------------------------------: --------- -Distance from nearest building-------------------------------------- 'T F1Distance to nearest of line--------------------------------- --- ------------ -------------------------------------- ---------------- --------------- Remodeling and/or repairing (describe):' ------- ---- ---- ------- if. -------------------------------------------- ------------ ------------------------------------------ I------------------------------------------------------------------------------------------------------------------------------- ------ 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) ----- ------- --------- - ---- ------------- ------------------------------------------------ .__(O nd/or Contractor) i ----------- (Title) -------- ---- - ------- By:-----------------------Q__ --------- t (Plot plan, showing size of lot, location of system l reiation t wells, buildings, etc., can be placed on reverse side). t i i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ------------------------------------` DATE----------- c y`� REVIEWEDBY--------------------------------- - x DATE------------------------------------------------------------ --- ----------------------- ---------- ------------- BUILDING PERMIT ISSUED------------------------------------------------- DATE Alterations and/or recommendations-------- --------------- - ------------------------------•--------------------------------------------------•-------- -------_----------------------- ----- :{ _________________________________________________________________ 1 -----------------------------------------------------------_.____.__..-_.-------------------------------------- I ________________-_.._.---.-.---____-_.._--___.._.... ______----------------------------___--------- _----------------------_---------------------------- _----------------- ---------------------------- ------------------------------ ----------- ---" FINAL INSPECTION BY:----- f -- Date '' -tf° �' ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California . F.P.CO. i