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FOR OFFICE USE: ----- ------------------------------- -------------------------------------_-------------_--- IAPPLICATION FOR SANITATION PERMIT Permit No. .a� ------------------------------------- ----------------- (Complete in Duplicate) Date Issued --.--- f This Permit Ex fres 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 wit County Ordinance No. 549. QQ y� JOB ADDRESS A LOC TIO - - i�c"...... .--------- ---•----- _.2e.�a----- ` i ------------oma ------- - --------- ---- Owner's Name-------- ---- Phone 0 Address . ------------------------------ Contractor's Name ------------ - ---------•---- - _ --------------- Phone------------•-••----------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number.of-iivirig units: ---V.- Number of bedrooms Nuber of baths __--.- Lot size -_-__-._----_.___----------------------------------------- Water Supply: Public system E] Community system [—] Privatepth to Water Table �(�_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel Sandy Loam Clay Loam ❑ lay E] Adobe E] Hardpa ❑ Previous.Application Made: {1f yes date-----------.--------l No New Construction: Yes E] No FHA/VA: Yes E: No L"] 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--------------------------Caacit Nos al Field: Distance from nearest well---"0.----_--Distance from foundation_j_ i� J�___ Distance to nearest lot lma_-�.._.____. Number of lines---'----__--� Length of each line--.-�_______. Width of trench i/ /---------------------- ------- ----------- Type of filter material.-_ -A C• .- ------Depth of filter material----- -------- -----Total length---------6-0------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----=-----------------Lining material------ ----------------Size: Diameter----------------------.Depth----...-------------------------- 8 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----.--------------------------------- Size: Diameer---------------- D - --- ---------------- e th---------------------------_ -Li Liquid Capacity ❑ t:.s 1} - p - - G - --------------------------gals. Privy: Distance from nearest'well_.________________________________________...._Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-------------------------------------------------------------------------------------- Remodeling and/or repairing (descril e)----------------------r-----------------------------------•--------------------------------------•------------------------------------------------- -------- --- ----------------------------------------------------------------------------------------- - `� 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 e and`re la ons the San Joaquin Local-He'aIA"District. (Signed)----------------------- ----- ------------- - ------------------------------(Owner and/or Contractor) Plot Ian. showing size of lot location of system in relation to wells buildings, etc.-_c. _(btie)______________._____....__._._._.-_._. _--_._ _______ Y: --- -- -------- ( p g y g , an be placed on reverse side. 14k. , I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By = DATE..... r� - ----------------------------- REVIEWEDBY--------------------------------------:----- --------------------•---------------- ------------------------- •------ DATE BUILDING PERMIT ISSUED------------------------ ----------------. DATE_-------- --------- Alterations ------Alterations and/or recommendations:------------ :: ----------------------------------------------------------------------------------------------------------------------------------- t ----- ------------- a � FINAL INSPECTION BY: ___- _-_ ~--. _ --- Date..._-�_`-�_ SAN JOAQUIN OCAL 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 F.a,c o.