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FOR OFFICE USE: " -------- ----------------------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. - ------- --- ---------------- ----------- - - - -------------- - -------------------- -�-- -_ .------_.___. (Complete in Duplicate) Date Issued . This Permit Expires 1 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. 549. �`` r' -- � ------------- JOB ADDRESS AN LOCATIO lf1'?�_A_11 - Owner's Name------ ----- - ------------------------- Phone. ----- _ f-----"---------- -------------- -- ---- "-" --- Phone----------------------------------- Contractor s Name____________________ " - --'-"-"•"'""" Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer ourt ❑ Motel ❑ Other ❑ Number of living units: _,/-___ Number of bedrooms.- Number of baths ___-____ Lot size ._.. ---- -----------------N Water Supply: Public system ❑ Community system ❑ Private eDepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ 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.) i Septic nk: Distance from nearest welL�O Distance.from �foundafion--/p---- _.M at real No. of compartments..-.__`r"_____------Size ��'-"x-�� -'A!!!;!- - Liquid depth------ ____-__"____-Capacity_.fa/ __--- Dispos Field: Distance from nearest well---A—�____"Distance from foundation�o_.�____.____-Distance to nearest lot line Vis___._______. -___Length of each line_---FUt________________Width of trench..------------ - Number of lines._--------�--------- ''-•----------------- Type of filter material____._.__�j`• Depth of filter material-___._1-_4--_-__-___--Total length------.��__ f-10 -------------------- 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-----------------Distance from foundation--------.-----------Lining material_____..__-____.---------------- aIs. ❑ Size: Diameter---------------------- p _Liquid Capacity..------------------------ - Privy: Distance from nearest well------- -----------------------------------------Distance from nearest building.-------_____.-------------------- _-___ ❑ Distance to nearest lot line------------------------------------------------ ------------•---------------------- -----•--------- Remodeling and/or repairing (describe)----------------- ------------------ --------------------------•----------•-------------- --"-- ----------•--------•----------•---------------_-•---- ----------------------------------------------------------•---------------"---------------------- -----------•------•---------------------------- I hereby certify t t I have prepared this application and that the work will be done in accordance with San Joaquin County /v ordinances, State la d rules and re ulations of the San Joaquin Local Health District. end/or Contractor) (Signed) -- ----------------- -- BY� _------ (Title)------------------------- -------------- ---- ----- -------- 9 P (Plot plan, showing size of lot, location of syst m in rel ion to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- ----------------------------------------------------- DATE---- ---'- --------------------------- REVIEWED BY-------------------------------------------- ---------------------------------------- ---------------------------- DATE----------------------------------------------------------- - --- - - BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations-------------- --------- ---------------_--- ------..--------------------------------------------------.------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------- -------------------------------- -------------------------------------------------- ---- ---------------------------------- ---------------------------------------------------------- --- ------ ------ - -- -- -------------- -------- --------------------------------- ---- 2 FINAL INSPECTION BY- - --- -- -- -- -- - -Ll.�! - ---- ------------ Date-- l ------•- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.F.0 O.