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FOR OFFICE USE: ------------------------------------------- ------------- APPLICATION FOR SANITATION PERMIT /Permit No. �. .. " --------- --------------- ---- -- (Comple+e•in Duplicate) ... This Permit Ex ires 1 Year From Date Issued Date Issued �lS.-�� 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 L CATION/_�_ --- vu- l_'_�Xaf---4l-±-+. - '---=-�]'�G'ltiC� Owner's Name------- ....... -------------•---------- Phone------------------------------------ - Address-------------------------- --------�- --... k .�Z'4..1�1.... ------...-- ----- - -•- --- ----- ---- ------------------------------------------- k Name---- -- ----- ---- -/ - ----- -- .-- ------ ------ ------------------------------- Phone--------------------- Installation will serve: Residence WAparfmenf House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ....- Number of bedrooms... Number of baths ./.-. Lot size -__ - - - - ------------------------ Water Supply: Public system ❑ Community system ❑ Private �epth 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation------------------. Material ...-...-.-...._.-_._-__--.--..-------.__...-- No. of com artments...--.--- ---------------Size-------------------- -----------Liuid depth--------- ------- - Capacity Disposal Field: Distance from nearest well. Distance from foundation.___.-....___--.-.-.Distance to nearest lot line----------------- ❑ Number of lines ----------------------------------Length of each line-- ---------------------------Width of trench---------------.------------------- Type of filter material-------- _--------------Depth of filter material-........------......Total length_....-..-------------..____._-__-.-_--- Seepa Pit: Distance to nearest well..... _Bp._r.__Distance from�fjoundation-.--lFQ."'.._.Distance to nearest lot line---- _-__- Number of pits.-- ___---/.........Lining material-....c [14.t_._ Size: Diameter------33.".----Depth----;?--5.° Cesspool: Distance from nearest well ................Distance from foundation .----_----__ _ Lining material-------------------______-------.- ❑ Size: Diameter- -- --------- ----- ----------------Depth_ ---- - --- ------------------,------------Liquid Capacity--- ------------------------gINN-1 Privy: Distance from nearest well----...-------------------..............---------Distance from nearest building---------------------------------------- 0 Distance to nearest lot line---------------------------- ---- -------------•--------------------------•--------- Remodeling and/or repairing (describe):._._-- . ---------------------------------------- ----------------------" ---------- ---------- ---- - ---------- ---------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- ----- -" -- I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, Stat a s, and rules and reg ns of the San Joaquin Local Health District. (Signed)------ ----4:v-------"--------------- ----- - -- - - --------------------------------------- ------- ----- ----- -------------------�'er and/or Contractor) BY:------ ---------- --- -- - ---- -- {Title)------ ---"----- ----"----- -------- .............. (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ---------------------------------- REVIEWEDBY---------------------------------------- - - --- -------------------------------------------------------------- ----- ------ DATE--------- ----------• BUILDINGPERMIT ISSUED---------- -- ---------- --------------------------------------------------------- --"--- --------- DATE Alterations and/or recommendations:----------------- ------------------- -- ... --------------- ------- v-------- ------------------------------------------------- -- -- ------------•-----------•--•--------------- FINAL INSPECTIONDate._ ..�. f.'.- .....-- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.waxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press