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FOR OFFICE USE: ------ ---------------------------I------------------- ----- --------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .. -------------'---- --- - --- -- ----- (Complete in Duplicate) ' This Permit Ex fres 1 Year From Date Issued Date Issued -- - -------- ;'-------------- ----•--=--"---- Ol 7_040_4`9 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. 9E_;� t -- JOB ADDRESS ANQ CATION-. � 27'` �"�- .------. =" Owner's Name _ --- ------- ------------- ----------- Phone 14W --------•--•----•---------•-----•--- Address----------- _ --- --- -- ------ ------ 4' r Contractor`s Name------- ------------ Phone---------------------------------- Installation will serve: Residence`` ] Apartment,House F1 Commercial E] Trailer Court E] Motel E] Other ❑ Number of living units: ---J-_- Number of bedrooms _2�_ umber.o " baths J... Lot size ------------------ ------- ----------------------------- Water Supply: Public system El--Community.system ❑".,Private 'Depth'to V+/ater Table --.----- ft""' Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan E Previous Application Made: (If yes,date--------------------) 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.) A __-Distance from foundation-------------------Material------------------------------------------------" Se Tank: No.h of compartments--well- -------- ' Size---------------•------- t------Liquid dep/h---------------- ---- ---Capacity------ ------------- Dispos celd: Distance from nearest well-��..--- .'.Distance from foundation-----��-------Distance to nearest lot iine- __---_---- Number of lines-----------1..._.__._- '-Length of each line--------_t�Q- .........Width of trench.-- (---------..---_------- Type of filter material---------s�1R --_Depth of filter material-----f I.-11---_____.Total length---------G-0-------------------------- Seepage Pit: Distance-to nearest well-----------------------Distance from foundation------------------- Distance to nearest lot line--.-_---.__------ Number of pits----------------------Lining material------------------- --Size: Diameter-----------------------Depth.... ---------------------------- " :. Cesspool: Distance from nearest well----------------- from foundation----- --------------Lining material--.----------_-___-.--------------- E] Size: Diameter--------------------- - --------------Depth--------- --------- - ---------------------Liquid Capacity----------------------- gals. Privy: Distance from nearest well-------------------------'.----------------------Distance from nearest building_____..-----------------_----..-___.--.-. ❑ Distance to nearest lot line---------;----------------- -------------------------------------------------------------------------------------------- ---------------------- Remodelingand/or repairing (descri e)--- ---- -------- ----------`-----------------------------------------------------------------•-------------------------------------------------------- --------------------------------------------------------------•- --- ------------------ ----------------------------•---------------------------------- ------------------------------------------------------------------ -- --- ---- - -----------------------------------------------------------------•------------------------------------------------------------------ -- -- �. ------------------------------------ ----------------------------------- ---------------•--•-----------------------------------------------•------------------------------------------------ - ----------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aws, a rules and regulations of the San Joaquin Local Health District. ------__- -�. -----" ---- - - ---------------- ------"----------------------- ----------------------------- and/or Contractor) Si ned - ___ _ * (P plan, showing size of lot, location of system in relatio o wells, buildings, etc., can beplacedon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------- ------DATE__ - -6 ---------------------------- REVIEWEDBY------------------------------------- --- --------------------------- ------------------------------------------------------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------- ----------------------- --------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:-------------- - - ------ -------------------- -----------•----------------------------------------•----------------------------------------------------------- --- -------------------------------------------------------------•----------------- -------------------------------------------------------------------------------------------------------------------------------• ----------------------- ------------------ ------- -------------------------------------------------------------•------------------------------------------------------------------ --------------------------------- --------------------- ----------- --------•------------ ---------- ------------------------------ --------------------------------- ----------------------------------------------------------------------- FINAL INSPECTION BY Date_-...' ---------------------" ------- SAN JOAQUIN LOCAL 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.P.C D.