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FOR OFFICE USE: --------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. -------------- --------------- ........................ --- - ------------------------ - - ----- ----------------- (Complete in Duplicate)- Date Issued -!F _:._-d___--- 6 --_----------------------------------------- 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. JOB ADDRESS A LOCATION__'S_'C "'c----------4> �-�r --------------------------QQ�`'i Owner's Name------ - -- -------------� ------ •----------- --------- ---- - - ------------------------------------------ Phone---------- ------------------------- ----------------g� r ----•- Contractor's Name `` ---- Phone..--••----••--------••------------- Installation will serve: Residence [A/Apartmen+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_-_ Number of bedrooms _ Number f baths __ __ Lot size ----------___________-_______..__________________.-------- Water Supply: Public system [:1 Community system E] Private (Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Ciay 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----------------------- Dispos field: Distance from nearest well.... ___Distance from foundation---Za--- _.__Distance to nearest lot Number of lines______.___.._-____ y� Length of each line---IVO'---------------Width of french-------�---/-_______-----_______ Type of filter material_.._.._S�t'C_t.____Depth of filter material--____/__�-d___-`-'.-_._Total length______�.47 a-�________________ Seep Pit: Distance to nearest well____1_ _ ------Distance from 4ounclation----- _.�____-_.Distance to nearest lot line...S�---------- ID Number of pits._..______---------Lining material----_ 'j_ _'_...Size: Diameter.--__-7.�._r-_----Depth__. -------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation____----------------Lining material----------------._.________----._.._.. ❑ Size: Diameter------------------ -------------------Depth--------------------------------------------- -----Liquid Capacity- ------------------------.-gals. Privy: Distance from nearest well------------------___------------------_------___Distance from nearest building-----------------------------------------. - [] Distance to nearest lot line --------------------- ---*------------------- ---------------------- -------------------------------------i-y------------------------------ Remodeling and/or repairing (describe) �-------------------------------------------•- •-------------------------- ------------------------------------------------- ------------------------�-------------------•------------------ -------- ------------------=------- { ----------------------------------------------- ----- - ---------------------------------------------------- ------------------------------------------•-----------•--------------------------------------------- U ------------------------------I-------- ------------------------------------------------------------------•------------------------------------------------------------------------------------------------------- --------- I ------Y I here6y certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State aws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------- j------------- [[� ---- -- - ----------------------------- ------------------------- - ---------------------- nd/or Contractor) U' ±� {Title T �Y - - ::: _)_-_-___-- (Plot plan, 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__ __________ DATE___ __.__ _ - __�`...__--------------------------- REVIEWED -__ ._REVIEWED BY--------------------------------------------- ---------------------------------------------- --------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------- ---------------------------------------------------- DATE------------------ ---------- ------------------------------ Alterationsand/or recommendations:--------------------------------------------- -------------------------------------------------------- ------•----------------------------------•-•---------- ---------------------- ---------•-------------------- I-------------------- ------- ----------------------------------- --------------------------------------------------- -------------------------- ------------ ---------------------------------------- -------------- ------ --------------------- -------- ------------------ ---------------- - ----- ------------------------------------------------ -------------------------------------------------------------------------- FINAL INSPECTION BY �,��' qtr �T---------------- Date------ ----^---------.' ------------------------------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ha=elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC. f