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FOR OFFICE USE: ------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. _, _�___5..... ---------------------------------------------------•---- (Complete in Duplicate) Date Issued ------------ ...................................... This Permit Expires 1 Year From Date Issued Application is hereby made to the SaniJoaquin 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. 0 -- (590—13 JOB ADDRESS AN,D yLOC'ATTIIO,NN..'------- •- --u-_-QS-'r- -.�- �=------•--------- -----------------------------•---•----•• ............................---------_... Owner's Name /C.l.. .�-rte ----------------•- Phone.. Address-------------! ------ ----• ---- -- ---••------------------------•--•----------------------------------------------------------------------------------------------- Contractor's Name....... - ••---------------------------------------------------------------------------------------•----•------------------ Phone................................... Installation will serve: Residence r Apartment House ❑ Commercial E] Trailer Court [I Motel ❑ Other J__ ❑ Number of living units: _ .___ Number of bedrooms __'LIKlumber of baths ___/__ Lot size -�/ Community system Private Depth To Water Table AP ft. Water Supply: Public system ❑ C y y ❑ I� p 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 0 New Construction: Yes [XNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: , _ [J (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___9 ___Qis#ant fro fovunda�jion____ Q--------Material__ P No. of compartmentsr��_ _______---------Size_ _ ,1�_- t2Lid depth__.._____ ____.-Capacity._ _ _ _ Disposal Field: Distance from nearest well__ 4_-0_.._Distance from foundation___. i tante to nearest lot lin !T N Number of lines___. ___.-- -Length-of each line, - .�O.=L�=�.VPidth of trench._ _ _______________ Type of filter material._ Depth of filter material___JS-�______•_ g Total length Seepage Pit: Distance to nearest well__________________ ___Distance from foundation------------------..Distance to nearest lot line____.....________ ❑ Number of pits----._----------------Lininglmaterial-----------------------Size: Diameter------------------._....Depth--------------------------------- ' Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material_.----------------------------------- ,- 1 ❑ Size: Diameter----- I-------------------------------Depth--------------------- ------------------------:----Liquid Capacity..........------------------gals. Privy: Distance from nearest well-----------------------------------------------.-_Distance from nearest building----------------------------------------- ^y t ❑ "- -. a !` Distance to nearest lot line .----------•----------t- ----- ------------ ----------`-----------...----•--------•--------------•----------•--------------------- ----- �• Remodelingand/or repairing (describe):--------------------------------------------------------------`------------------------------------------------------------------------------------------ ---------------- --------------------------------------------- --------------------------------?-------- ------------ -----------------------•-------------------------------------------------------------- f G rr -----------------------------------------•---- ------------•--t ---------- -------------------- --------- __:.. •------------- ------ -•----•----------------------------------._._.. ...----------- ---- - ---- 1� hereby certify that I have prepared +his application and that the work will be done in accordance with San Joaquin County ; ordinances, State laws, and rul s and regulations of the San Joaquin Local Health District. (Signed)--- -- ---- ; (Owner and/or Contractor) t. (Plot plan, showing size of lot, location of system in relation to wells,-buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY---- ----- -- = DATE r REVIEWED BY--------------------------------------------------------- •- -- 'DATE-------- 1 --�--�--------------- BUILDINGPERMIT ISSUED------------_------------- -------- -------- .. ------------------------ DATE------------------------------------ ------- ----------- Alterationsand/or recommend'ations------------------ --- -------------•------------ - -----------------------------------------------._._.-----------------------------------------------.------ ---------------- -•--------------------------------------•---------------•-----------------------------------• •------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------- -- ---------------------------------------------------.--------------------------------...-----------------------.---••--•-------------- I ----------------------------------- - - --- ---- ----------- ... ---- ---•--. -----------------. ..-.------•-•----------------•-----------•-•--------------- ------------------------------------------------- FINAL INSPECTION BY: - Date-------------- .` - -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 2M 5.62 ATLAS