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FOR OFFICE USE: ----------- ------- -------------------------- ------- --------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No, -- ------ ........... ------- ---------------------------------- ------ (Complete in Duplicate) �- �- This Permit Expires 1 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.incompliance with County Ordinance No. 549. 00,3 _ IC 0- O74� JOB ADDRESS AND LOCATI N_ _+ __ - -- --` - - { -------- Owner's NameL 6zt- .__.... - -•--------------------------------- - - ------ -------------------------------- Phone------------------------------------ Address '.'_.._ . s - Contractor's Name------- � ---- �---- ---- - --r-- --- --- -- ---------------------• - ----- Phone----••-•-------------•----------... - Installation will serve: Residence 2/jApartment House ❑ Commercial ❑ Tra-ler Court F] , Motel ❑ Other F]Number of living units: --../ Number of bedrooms _ _ Number of baths~'______ Lot size - --- ----------------------------- 11 C/ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ? _-_-_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam E] Clay Adobe [❑ Hardpan ❑ 13, Previous Application Made: (If yes,date---------_------------.1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 6 TYPE OF INSTALLATION AND SPECIFICATIONS: f ('Fj (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesr well-----------------Distance from foundation--------------------Material._.______._.____.._____._______._....___.____. ❑ No. of compartments--------------------' . Size--------------------------------Liquid depth-------------------------.Capacity------------------- Dispos Field: Distance from nearest well-----�r_p��_Distance from foundatiion__� :o--_�__-.Distance to nearest lot line----- Number of lines______________ ________------------Length of each line-----c59�-----7---=-MWidth oftrench.___y._�___.._...__...___-___ Type of filter matenal------.____s�1�_}__Depth of filter material---- _Notal length___c 'O_. ___________________________ Seepag Pit: Distance to nearest well------1_4�v------Distance from foundation____(0---------Distance'tb nearest lot line__--6-_..____._ Number of pits--'------I-----------Lining Material------5_. -------.Size: Diameter--- _ _•._--.-_--Depth_-..- S--------------------- 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 Remodeling and/or repairing (clescribe):--------- --- ° t ''' -- ----------------•---•- ------------------------------------------------------------------------------------------------------------- t ,w -----------------------------------------°----------------------------------------------------------- ---------------------------------------------------- ------------------------------------------------------------ - ------------------------------ -----------------•-------------------------------------------------------------------------------------------------------------------------------------------- ----------- --- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I S. nd rules and re ulations of the San Joaquin Local Health District. (Signed)--------------------- - = ------fie{ and/or Contractor) :.By:-------=--- --- -=----------- 4=--------------------------------------------------------(Title)--------------------------_ ------: -------------------- (Plot plan, showing size of loft, location of system relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------------------------------- DATE----(a -- ------------------------------------------------------ REVIEWEDBY--------------------------------------------- --------------------------------- ---------------------------------------------- DATE------------------------------- BUILDINGPERMIT ISSUED---------------------------------------- ------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations--------- ----------------- - ---- ------------------------------ ---------------------------------------------------------------•----------- --------------------------------------------- ------- •-------- -----------------------------------------_----------------------------------- -------------------------------------------------------------------------- --------------------------------------- ------ ---------- --------- ------------------------------- - ----------------------------------------------- ------------------------------------------------------------- FINAL INSPECTION BY:_. y� . _•__'----- �''------ Date �-L -`� -------------------------- ------------------------------ --- i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 5tocklon,California Lodi,California Manteca,California Tracy,California F.P.C❑.