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' - FOR OFFICE USE: "— I ------------------- - ------------------- � _________ __________________ _______________ --------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ------------------- ------------------ - (Complete in Duplicate) 3 ---------------- --------------- . -- 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 in compliance with County Ordinance No. 549. • JOB ADDRESS AND CA ION._4__- Owners Name ------------- Phone Address .. •• /d ' Contractor's Name-------- ------------------------------------------------------------------------ Phone 2 716 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -,� Number of bedrooms Z___- Number of baths,-___- Lot size __- < •--t-r_ Water Supply: Public system ❑ Community system ❑ Private ®Depth to Water Table.,L—iCft. Character of soil to a depth of 3 feet: Sand 21'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClaY ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------- No ®" New Construction: Yes ❑ No [�J-- FHA/VA: Yes ❑ No TYPE OF.INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is Distance from nearest well_________________Distance from foundation-------------------Material--_-_..._-____.-___---.._________--__.____._____. No. of compartments----------------------- --Size_-------------------------------Liquid depth--------------------------Capacity-------------- ---- r Disposal Field: Distance from nearest weil_•.rV__------Distance from foundation__1..�___r---------Distance to nearest lot line--rf { Number of lines___________/----.________ .____Length of each lines?a -C-a r-__.Width of trench--_L__`__----- - �E � --o s------ Type of filter maf erial_- __Depth of filter material___L8_-__________Total length_-_-. -- -E-a----- ---- Seepage Pit} Distance to nearest well_-------------_.......Distance from foundation-------.------------Distance to nearest lot line----------------- a ❑. •_ Number of pits------------------ --Lining material--------- ------------Size: Diameter-------------------------------- Depth----------- ------------------ Cesspool: , e+x>- well-----------------Distance from foundation--------- ----------Lining material_----_________________________ -•--- Size: Diameter ---- - ------ e th------------------------------------ ------L+quid Capacity----------------------------gals. Privy: E Distance from nearest well------_------- ----------------------------:_._• _Distance from nearest building g ❑ Distance to nearest lot line - ------------------------------------------------------------ r F Remodeling and/or repairing (describe)---- ---_-------------------------- -------------------------------------------- ---------------------------- ------------------------------------------------------------------------- ---------------------------- --------------------------------------- -----------------•--------•------------------------------------------------------------------------------------------------------------- ------------ 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 regulations of the San Joaquin Local Health District. el (Signed)_ ,Q -- ------- --- -------- ---- -' �.i"1.r------ ------------------------------- ------- -----------(Owner and/or Contractor -------------------------- BY� ---- r = -----------------------------(Title)------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________ __ -�� DATE-_____._ ___ S1- ----- ------------------------------------------------------ REVIEWED BY -------------------------- ----------- -------------- DATE------- ----------------------- BUILDING PERMIT ISSUED------------- ------- ----------------------- ------------- DATE--- ----------•----------- terations and/or recommendations__________________ ------------- --------------- ----- ----------------------- -------------------- -------------- I qr i FINAL INSPECTION BY:.. � . _----- ----�� --------------- --------------- SAN 1 ---- ------------ ADate--------- UIN LOCADISTRICT (� 1601 E.Ha:etton Ave. 300 West Oak Street 124 a Sycmore Street V(\ q 4 205 West 9th Street r Stockton,California Lodi,California Manteca,California Tracy,California F.RC C. 1n