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FOR OFFICE USE: = 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. b S/ - j2, — 6 2- JOB JOB ADDRESS AND LOCATION______-_--_-__".-------- �"tca Owner's Nam ! •.>�a.._�c.__ 4 - a1------------------------•- ----- _ -� _ - -------------------------- Phone_ Address--------- �� y -------------------------------------------•------------------------------------ Contractor's Name-------------- - ' j`" Phone.--. Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/.'.._ Number of bedrooms�l_- Number of baths __ Lot size ____._�� R_""""__._"""_"""_"."". ~• Water Supply: Public system ❑ Community system ❑ Private e Depth o Water Table -------- ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamClay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: [if yes,date---.----------------) No ❑ New Construction: Yes ❑ No ❑ 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__..' _Q__"._Distance from foundation------/_v__._._.Material------ .-______._....._.a _. [ No. of compartments-------�-_---------Size"r`__J�f�Af_ `L'iquid depth-------&4...............Capacity----f Disposal Field: Distance from nearest well...._?_ _.=Distance from foundation_--../.a_._'_._..Distance to nearest lot line_„-"./ Number of lines--------------------------- -_"-_.__Length of each line------ 41--'_--.---_--- Width of trench__,?�---- of filter material-------c '_ __-------Depth'.of filter material-_.__ _ _°__..___Total length_._._ ._�__________________� Seepage Pit: Distance to nearest.well_______ ____'-._____"Distance from foundation--------------------Distance to nearest lot line-_.____...._.--� � ❑ Number of-pits------------------ - -Lining material---------- ------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance'f,om nearest well"--------- ------Distance from foundation--------------------Lining material_._."""__-_-____.__.._.._...__._...__- r 0 Size: Diameter-- ----------Depth----------------------------------------------------Liquid Capacity--- ------------------------gals. Privy: Distancefrom nearest well-------------------------------------------------Distance from nearest building.----.__--_----_-___-----_------_..._ ❑ Disfanceito nearestdot--line-:- - -------------'----------------------------------------------------------------------------------------------- i Remodeling and/or repairing (describe)-------- -------1---------------- --- ---------------------------------------------•----------------------------------• Y----------•------------------- I "_"..""_____________"""_.""_""____-__"_..___-"_"______-_--_---______.______._.-_----_"_________-"-""".-_"_------_----------_-_-____"__-"-"__________-_."..____"-"____"-"----•____-------------------------_.......... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat a s, and rules and regulations of the San Joaquin Local Health District. (Signed)------ --- -------- ------ --- ----- ----- ------- ----------------------------------------- ----------------------------------------------...._ e and/or Contractor) BY= ----- ---f ---- -- ------------ - ----- {Title) (Plot plan, showing size of lot, locatie of system in'reldtio`n to wells, buildings, etc., can-be placed on-reverse side)._ a FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY_L. -'' "`' --------------------------------------------------- DATE---- ---- ---------------------------------------------- REVIEWED - f--------- ------------------------ REVIEWEDBY------------------------------------- ----------- -------------------------------------------------------------------------- DATE------------ ---------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------- ------------------------------- ---------------- DATE------------------------------------------- ----------------- a Alterations and/or recommendations:--- ---------------------- ---------------------------------------------------------------------------------- -------------------------------------•---------- ----------------------------------------------------------------------I-------------- -- -------------------------------------------------------------- -------------•------------------------------------------- ------ FINAL INSPECTION BY:- ? .�... _ Date../_U..--f �G/.-------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street j I Stockton,California Lodi,California Manteca,California Tracy,California r.F.CO.