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FOR OFFICE USE: ---------_s? __- APPLICATION FOR SANITATION PERMIT Permit No. 1. ............... ------ --- ------------ ------ ----------------------- (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 N 549. JOB ADDRESS AND LOCATION... / r'' -----—---------- ------ ------------------------------------------•----------••------------------------------ Owner's Name--- --f---- -- --- Phone...... ---------------- Address � __ .... -----------------•---------•-------•----------------•------- Contractor's Name---- - ----- ------------------ ---------------------------------------------- Phone----------------------------------- Installation will serve: Residence U?Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... Number of bedrooms A_ Number of baths -!e�__- Lot sizeX/ ------------------------- i Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑Gravel_❑ Sandy Loam E] Clay Loam El Clay El Adobe Hardpan C] Previous Application Made: (if yes,date____________________) No Ro'�`New Construction: Yes ❑ No ® FHA/VA: ,Yes ❑ No Kj— TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se c Tank:,, Distance from nearest well-----------------Distance from foundation--------------------Material...-.-___--._-._......_.-.__._..________._..__--- A-5isy�#* No. of compart,ents--------------------------Size------------------------- :_..Liquid ciepth---------------f'----r--Capacity------ ---------------- Di�osal Fields Distance from nearest well-.-?! A_..Distance from foundation----�O_-..-.--Distance to nearest lot line-AA: -.. Number.of,lines. ........... . ....... Length of each-line..-�pQ.. __._._.Width;,of trench._ . ._-...__ _......__.:... Type of filter Depth of filter material--f p� material____., _-_..,_Total length___,�Ipa------------ ------ Seepage Pit: Distance to nearest well.....- Distance froJJ�� fau 'dation..f ....... s to nearest tot lir ..... ........... Number of pits___--.-/--------Lining material----A .Size: Diameter_______________________Depth"?W- _ . s Cesspool: Distance from nearest well------------'_-_Distance from foundation--------------------Lining material------------------------------------- IDSiz ep: Diameter------ -------------------------- ---Depth------------------------------ ------- ----- Liquid Capacity----------------------------gals. Privy: Distance from-nearest well_--------I Distance'from nearest building------------------------------------ ----- ❑ 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 San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. a (Signed)----------------------- --------- J � �. ( or Contractor) By:---------------- = {Title) . (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). A FOR DEPARTMENT USE ONLY f PPLICATION ACCEPTED BY_------------- ------- -----' --------------------------------------------- DATE---------- 'REVIEWED ----- --- ------------------- REVIEWEDBY------------------ - --------------------------------------------- DATE---•-------------------------------------------------------- BUILDING PERMIT ISSUED-------------------- - --------- DATE---- ------------------------------------------------------ Alterations and/or recommendations:.-.-- - ------ - -. �.------ c�{1�/� t---- �_.d�-------------------------------------------- - --- - -------------------------------------- ----------- ------------- ----------------------------- ------------------------------------------------------------------------------------------------- ----------------------------- --------------------------------------------------------- --------------- ------ -------- ----------------------------------------------------------------------------------------- ------ -------------- FINAL INSPECTION BY:---- =...... ---------------- Date----------- �� / 'f' - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.