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FOR OFFICE USE: ------------------------------------=----- -r----------- q4 --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .f..� -------------------------- ------------------------------ (Complete in Duplicate) t`G 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 work herein described. This application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOCATIONAW_-- " Owner's Name=- O - --- -- -------- ------ Phone Address------- ------ -•- ----------------------•---- Contractor's Name----------- s - - ---- --- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. ---!- -- Number of bedrooms -Numb 'baths baths -4--- Lot size --�- F:--------._------------------------- Water Supply: Public system E] Community system El Private j Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam E] Clay Loam ❑ Clay [dobe ❑ Hardpan ❑ Previous Application Made: llf yes,date----------- -----1 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--------------- E1 .----.-❑ Number of lines-----------------------------------Length of each line--------------.--------------.Width of trench------------- ------ Type of filter material------------------------- of filter material-------------_---------Total length_.__--.___--_-_----.--------------.---. r Seepa Pit: Distance to nearest well-----`e��?-------Distance from fQundafion---IR-----------.Distance to nearest lot line----------------- Number of pits---------1-----------Lining material--.--- --13d ._Size: Diameter------- Depth----- -------------------- i 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.-------- ------------------ ---------- --•------------------------------------------------------------------------------- Remodeling and/or repairing (describe)------- --------- -------------- — , --------------------------------------------------------------- - . k 7- ----------------------•-------------------------------------------------------------------------------------------------------•--- •--------------------------------------------------------------------------------- ------------------------ ------------------------------------•------------------------------------------------------------------------------------------------ ------------------- ------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la nd rules and regulations of'the San Joaquin Local Health District. f (Signed) --- --------------------------- --------------------- - ----------------------- ----- - -- ------ and or Contractor r BY: F- -'-------------------------------------- ----------- -{Title)---------------------------- (Plot plan, showing size of lot, location o syste' in relation to wells, buildings, etc., can be placed on reverse side). . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_- ---- -. - - DATE......r---_- REVIEWEDBY---- -------------------- -------_--------- --------------- -- ------------------ ------------------- -------------------- DATE----------------- ------------------------------------ BUILDINGPERMIT ISSUED-------------- ---------------------------------------------------------------------------------------- DATE------------------------- ------------------_----------- Alterations and/or recommendations------------------- -------------------------- - ---------------------------•----------------------------------•--------•-----------------------------------•--- FINAL INSPECTION BY:- lt/ 1 _--------- --- Date_ - -!.. r�+/i SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C O.