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rUx Urri-E USE: -----------------------------------------------------•- -7 ' ------------ --------------- --------------------- APPLICATION FOR SANITATION PERMIT Permit No. .. - -------- --------- ---------------------------- -------- (Complete in Duplicate) --------------------------------------------- ----------- r This Permit EX12ires. 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 AL JOB ADDRESS AND LOCATION__-. _ 1 - a p, I Owner's Name----___--r.�r' r ?rtn = --- - - --------------------------------------- Phone------------------------- Address---- ------------- ----- -----------------• Address ---' -------- ----- Contractor's ------------••---------------------------------- ---------------------------------------------- Contractor's Name - _ ------- Phone----------------------------------- Installation will serve: Residence d Apa ment House ❑,LCommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1__- Number of bedrooms .__T- Number baths ___ Lot size ___�C7_A � Water Supply: Public system ❑ Community system ❑ Private Depth Water Table __.----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan I E] l Previous Application Made: (If yes,date---__---__------ __I 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 ank: Distance from nearest well____�Q_.___ Distance from foundation-----Ap---r___-.Material--- �a�'[_°+�.�c.�., � No. of compartments------.✓--------------Size_d� ��i'10`,�'_ �,f_Liquid depth------�/---------------Capacity.-----` Dispos Field: Distance from nearest well ...Distance from foundation.-/ -------Distance to nearest lot line—:5___- Number of lines_'____________ Length of each line_-_.____ ' _---.__.Width of trench.---- .-`---_----------------- ------ _--__-_--- I _. �;- Type of filter material___.____ / _.__-.-Depth of filter material_____/�'`--_______Total length----- -`_---_ ------------- Seepage 1'i+: Distance to nearest well--------------- _______Distance from foundation-______________.__.Distance to nearest lot line_=___-_-_.___.._ ❑ Number of pits-- --- -------Lining material---------------------- Size: Diameter-------------- -------- p Cesspool: Distance from nearest well--------------_Distance from foundation------------------..Lining material__ ❑ Size: Diameter--------------------------------------Depth------ ---------------------------- ------- - ------Liquid Capacity- ------------------=--------gals— 4 Privy: Distance from neF arest rwell--------_------------------- ---------------------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, StatAsizeof s regulations of the San Joaquin Local Health District. (Signed) / C t + ) . .._. ,.By--------•-- . ---- an r on rat0 or-------------- -- ---------- (Plot plan, showiocation of syFem in relation to wells, buildings, etc., can be placed on reverse side). r r FOR DEPARTMENT USE-ONLY. APPLICATION ACCEPTED BY----- �,7 -------------------------- =:-- DATE:---- 1--_�-�_--' -------------------- ------------------------------------ REVIEWED BY ------------- ----------------------- -:: DATE ------------------------------------------------------ ! DIN PERMIT ISSUED_---------•------------------------------ ------ DA•TE- Aterations and/or recommendations:__,______________ _ # ------------ ---------------------------------------------------------------------------------------------- I - ---------------------------------------------------------------=--------- ---------- ---------- ------------------L------------- -------- --------------- - ----------------- ---------- FINAL INSPECTION BY: Date 7G SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Sfreef 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P,L:O.