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FOR OFFICE USE: �1¢3�?_ --------------------------------------------------------- p�• APPLICATION FOR SANITATION PERMIT Permit No, ___� ..1.P..._.... ----------------- -- --------------------- (Complete in Duplicate) / Date Issued --------------------------------------------------------- This Permit Expires i Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor -herein described. This application is made in compliance with County Ordinance No. '549. 4 JOB ADDRESS AND LOCATIONS ---y' 1-----.gii"' t �2 ------- •- - Owner's Name------ pPhone---------------------------------- ---------------------- x -Address ---•-------- - Contractor's Name-- ` _�----------------------- -----------------------•---------------------- Phone___-------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units:'-~ Number of bedrooms-.—Number of baths ---------t6t"size`-`-_____________________________________________________-__ Water Supply: Public system ❑ Community system ❑ Private rf Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam n 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. Septic Tank: Distance from nearest well----- ------Distance from foundation--------------------Material_____________________________________________-_- ❑ No. of compartments------------ -------------Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well-------------.---Distance from foundation-------_------------Distance to nearest lot line----------------- El Number of lines--------------------- -------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ IS Seepa Pit: Distance to nearest well....jaa__._-___-_Distance from foundation---Z?5�- ........Distance to nearest lot line_________________ Number ofp'ts-------f-------------Lining material-----_ ` ` __.......-Size; Diameter----W Depth--- 2 ' Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material_----_------_---___-__---___-____--_-. ❑ Size: Diameter----------- -------------------------Depth---------------------------------------------------.Liquid Capacity---------------------------gals, Privy: Distance from nearest well------------------------------------------------- from nearest building------------------------------_- _____ [] 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -------------------------------------- ------------------ - --------------------------------- and or Contractor $y:---------- ------------------------------ ------------------------------------(Title)-------------------------------- ------------------------------ (Plot ----- ---- -- -------------- (Plot plan, showing size of lot, location of sys m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 4� ------- DATE--- f �. V" APPLICATION ACCEPTED BY-------- ---- ----- -- - - ------------------------------•--•------------ --•---------------------- - REVIEWEDBY--------------------------------------------------- - ------------------------- ---------------------------------------------- DATE------------------------ ---------------------------------- BUILDINGPERMIT ISSUED------------------------------------------ --------------------------------------------------------- DATE-------•-------------------------------------------•-------- Alterations and/or recommendations:------------ ---------------------------------------- ----------------------------•---------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------- --- -------------------------------------- --- ----- ------ -------------- ---------------------- -------------------------------------- -• --------------- ------------------------------------ -------------- ------ FINAL INSPECTION BY:_-- ----------------------- - --------- Date.... --.----/.-_-_--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California