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- FOR OFFICE USE: ✓ t ----�--�=G�- -----�--- row- --- j�;y/ f APPLICATION FOR"SANITATION PERMIT Permit No. �.................. ----------------------- -- [Complete in Duplicate) -------------- ------------------------------------------------------ - Date Issued _3--3__`___-. -----------------------------__.------,------------------ This Permit Expires 1 Year From 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. ss�� a JOBADDRESS AND LOCATI N fl4_ - - __�-_'�__'----------------- ------------------------------------------------- ------------------------------- Owner's Name----------�----------- -•----------• ----------------------------------------------------- ------------------------------------- ------ Phone.---------------------- - Address „----------------------5-------------------------- ----------------- -- Contractor's Name_______s: - --------- ------------------------------------------------------------------ --------------------------------------------- Phone---••-•--------------------------- Installation will serve: Residence gp-'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1____ Number of bedrooms __3__ Number of baths _1---- Lot size -----------------------------1 Water Supply: Public system 2--community system ❑ Private ❑ Depth to Water Tablel_fa_0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ tClay ❑ Adobe Hardpan 11 Previous Application Made: (If yes,date--------------------) No RT"- New Construction: Yes ❑ No e FHA/VA: Yes ❑ No t TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , Septic Distance from nearest well-----------------Distance from foundation--------------------Material---.._______._..__..___.__________..___..____.._. No. of compartments.- ------------ - P ---Size-------•------------------- ----Liquid depth---------- ---- - - ---- .Capacity----------------------- D;sposal Fi I : Distance from nearest weft___''—_._._._Distance from foundation----Lt2...........Distance to nearest lot line__,:�-_--_._____ [Gr Number of lines-------1---{---------------- Length of each line-_-,3�`_..____________..Width of trench------!9_1--- Type,of filfer.materiaL 7778 � S____Depth of filter material____/_2.............Total length------ A ' Seep Pith Distance to nearest well_=_-------------Distance from foundation----/�________.-.Distance to nearest lot line-a------------ Number of pits---- ________________Lining material__T (rj(_____-Size: Diameter--Z-3............Depth____-_)___________-__- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-------- Size. Diameter--------------------- -------_____Depth---------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-_------ --- - from nearest building------.--___-_.______________..._._..___. ❑ Distance to nearest lot line__`------------------------------------------L---------------------------------------------------------------------------------------------- Remodeling and/or repairing {describea----------------- -------------- =--------------------------------------------------------------------------------•------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------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 a regulations of the S n Joaquin Local Health District. (Signed} ................ . --• ------. = - ----------------------------------------------------(Owner and/or Contractorl By:------------------------------------------------------------------------------------------ -------------------- --------------------(Title)--------- ------------------- ............. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•---- -- -�--- -----_-_� ��--------------- ------------------- DATE------ 5. ��----------------------- REVIEWEDBY--------------------------------- ------ -------------------- ------------------------------- ------------------ ------ DATE- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------=-------------- DATE------------------------------------- ----------------------- Altera#ions and/or recommendations:.--------3._7-_,1 ------------------I-------------------------------------- ---------------------------------------- ------------------------------------------------------------------- -------------------------------------------------------------------------------- ----------------- ---------- ------------------------------- ......... ------- - ------------- - -------------------- ----------------- -------------- ------------------------------------------------------------------------------------ FINAL INSPECTION BY:----- "==`----- ,"---------- Date---------. ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.1•]azelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California