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FOR OFFICE USE: - _—� _ ------------------------------ --------_---_------ APPLICATION FOR SANITATION PERMIT Permit No. . ---------------- ------- ---------- -------- (Complete in Duplicate) ----------------- --- ----- This Permit Expires I..-Year From Date Issued 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 complie t e with County Ordinance No. 549. JOB ADDRESS AND` - ,. Owner's Name :..ezz � -- - - Phone i. Address--------- Contractor's -------Contractor's Name ----- --- -- --------------------------- ----------------------------------------------------- Phone----------------------------------- Installation will serve: Residence'Pq"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: _,/-- Number of bedrooms -&2- Number of baths __4__ Lot size __��_��-�1,��------------------------------ Water Supply: Publics stem f pp r y Community system ❑ Private ❑ Depth to Water Table��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe 0--nardpan ❑ Previous Application Made: (If yes,date......... ......f No New Construction: Yes ❑ No iFHA/VA: Yes ❑ Nom' TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank ort cesspool permitted if public sewer is available within 200 feet.) A Septic Ta�nnki Distance from nearest well_________________Distance from foundation-------------------- AGs�i� No. of compartments--------------------------Size-------------------------- --Liquid depth--------------------- ----Capacity------------- -------- Disposal field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line----------------- R.1 Number of lines-l---------------------------------Length of each line-----------------------------.Width of trench---- Type of filter material----------_---_------_----Depth of filter material-----------------------Total length-------.____________________ Seepage Pit: Distance to nearest welt___.-----"- -------Distance fr m fo dation_Jo` _________Distance to nearest loft �^ Number of pits__1___Z_____-_.__Lining material_/__ B __Size: Diameter._,�?r'______......_Depth-o? �- Cesspool: Distance from-nearest wall--------------.__Distance from foundation.............__.__.Lining material-----..____________.__._--.____.__.. Size: Diameter--- ------------------------------- Depth---------------------------------------------------Liquid Capacity---. -----gals. Privy: Distance from nearest weft_____________:I i __Distance from nearest buildin --------- g-----------------------------------7Distance to nearest lot line----- ------------------------- .. -------------------------- j Remodeling and/or repairing (describe):_..._____-__ a , I -W_ __ -----------_______________________________,_--------------------- _________________-�_--________.___-_____.______ _____________-__._______.______________ i 3 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 re ulatio of the San Joaquin Local Health District. 5i ned ______________-_.-.(iDwy �or Contractor) ' { 9 -------jron -- --- $Y: ----------(Title)... 2�. ------ ------- -- --- + (Plot plan, showing size of lot, location of system in to wells, buildings, etc.; can be placed on reverse side). ! I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------�__-----------------------------� f +� - -- ------------------------- - -------------- DATE--------------f- �-�-------------------------------- REVIEWED BY ---- DATE--- ------ ---------------------------------- BUILDING PERMIT ISSUED---------------- ------------------------------------------------------------------------------------- DATE --------------------- Alterations and/or recommendations:__________________-------------------- t ------------- ------------------------------- --------- - •-- ---------------------------------------------------------------------------------- ---------------•-------- -- -----------------------•--------•------•--- ---------- ----------------------------------- ------------------------ - ---------------------------------- ----------------------------------------------------------- ----•---- ------------------------------------ •------------------------------------------------- •-------------------------- ---- ------------------------- ---------------- _ g FINAL INSPECTIONBY:-----------�---- n Date SAN JOAQUIN LOCAL HEALTH DISTRICT! 1601 E.Ha:ellon Ave, 300 West Oak street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California A LL Manteca,California Tracy,California