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FOR OFFICE USE: `. -------------------------------------------------------- d21�2?x 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 in compliance with County Ordinance No. 549. , JOB ADDRESS AND ATION__--- ..__/ __(�yC v._49" -------------- --------------------------------------;------------ . Owner's Name----- -- -- ------ ---- •--- ------ - ----•--------------- ------------------------------------------ .. Phone-_-------------------------------- Address------------- ----------------- - Address------------- ---- ----i--- - - ----- - `---�----- ------------------------------- - - - C�---'-`°�--------------------------------------------------------------- ------ Contractor's Name------------- -----'r`•---- --•------ - ------ ------- ------------ ------ Phone----------------•-----••----------- t Installation will serve: Residence Apartment House ❑ Commercial ❑I Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____1_ Number of bedrooms__ Number of baths _:_: ot size __---_____ --------------------- --------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth.toWater Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ['Clay Loam [] Clay ElAdobe [] Hardpan ❑` Previous Application Made: {lf yes,date----------_ ___,._) No E] 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 204 feet.) Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material________._-___._.____.______-_____-_-_-______- [] No. of compartments- ----- ---- -------- ----Size-------------------------------Liquid depth---- --- Capacity------------------ . Disposal field: Distance from nearest well__ 40"___Distance from foundation-___!4------------Distance to nearest lot line-__--_- ..�__. I Number of lines-----_-----I---_----------------Length of each line_____So--------------------Width of trench.- �------------------------------- Type of filter material-------6_41---__.__Depth of filter material.-- -----Total length------------------------------------------ Distance ___---- _t_________________________Distance to nearest well----- '_.___Distance from foundation---_/- -_ _____.Distance to nearest lot line---S----______ ❑ Number of pits----------I-------.--Lining material------$.&........Size: Depth_._1-,?-- ------ Cesspool• Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- 1-1 Size: Diameter-------------------------- ----- -----Depth------------ ---------------------------------------Liquid Capacity-.--------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------._.______._______________..._. ❑ Distance to nearest lot line-------------------------------------- --------------------------------------------------------------------------------- ----- --------------- Remodeling and/or repairing (descri _.....__. ----------- _____ _ ---------•--••----•-------------------------------------------- -- ------------- ------------------------------ ------------ -- ------- ------- - ------------------- --- . i ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. (Signed)-------------------- ---- = and/or Contractor) -+ - - -- ------------ ----------------------- Title (Plot plan, showing size of lot, location of system in r lation to we11s, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y__e_. ____________________ DATE_s.l. - _"_ _� � -- ------ ----------------- REVIEWEDBY------------------------- ------------------- ---------------------------------- --------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- ----------------- DATE------------------------------------------------------ ----- Alterationsand/or recommendations------------------1-- ---------- --- --------------------•-----------------------------------•--------- ---------------------•----------------------------- ----------------------------------------I----------------------------- ----------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------- ------- -- - -------------------------------------------------------------- -----------------------•------------------------•---- ------------------------------------------------------------------ - 1 -------------------------------------------------------------------- ----------------------------•--------------------------------------------------------------------------- i FINAL INSPECTION BY -- -------------- Date--Sr-/- ------------- --------------------------------- I€ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F,RCC. u