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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. 0(-7- 02 0-0-5 JOB ADDRESS AND LOATION///_0 - ------/,4,,_/..------ ------ ----- Owner's Name .!vir+- �. " � f/ ! --- - ---- ---- Phone___------------------••--- .... - Address r =' �" ./"�.!�! _. ... 1�. �� -Y ------ ------------------------------------------- Contractor s Name_l___r---- -7-pa-irtment �-- -------•-------- ----------- Phone---------•----------_---•-------- Installation will serve: Residence House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: Number of bedrooms __.___._ Number of baths-_1.-- Lot size -- -- .l- ------------------------------ Water Supply: Public system C1 Community system E] Private Depth to Water Table -7-6 ft 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 ❑ 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.) k a Septic Tank: Distance from nearest well-----------------Distance from foundation-.------------------Material ----..---------------------------..-_____--_-_. 1 ❑ No. of compartments-------------------------Size-------------------- ------- ---Liquid depth--------- ....... ........Capacity----------------------- Disposal Field: Distance from nearest well.---------Distance from foundation-__�O----------Distance to nearest lot line__ ........ Number of lines.-----/--------------------------Length of each line._ .....;L_0_'._- ----.Width of trench...��.�----------------_._ Type of filter mate ria _ ------------Depth of filter mater�al_._._f_9..h -------Total length__19`4�-.0____________________________ Seepage Pit: Distance to nearest well...a-.V_---------Distance from foundation----3_Q_ ........Distance to nearest lot line__r!------ -- Number of pats.__ ..______________Lining material_ �'.-.� ___ Sae: Diameter---,3:3 .__..____Dept ______...___...-__. Cesspool: Distance from nearest well ----------------Distance from foundafiion----------------- _ Lining material__. ---- ---------------- � ❑ Size: Diameter. - - - -- --------- - ---Depth------ -------- --------- ------ ---------- ....--Liquid Capacity--- •---------------------..gals. Privy: Distance from nearest well _------------------------__-_--..-_._-........Distance from nearest building-.-----------------------------_.___-..._. ❑ Distance to nearest lot fine - ------- ------------- ---------------------------------- ---------------------------------------- Remodelingand/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. (Signed)-, ----- ----- (Owner and/or Contractor) -_=-�'— --- - ------ ---- ------(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 , --------------------------- ______ DATE----- '3 ` -7 ---------------- ----------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------- --------- ------ DATE BUILDINGPERMIT ISSUED-------- -- - ----------------------- ---------- --------------- ---------- ------- --- ---------- DATE------------------------------ ------------------------------ Alterations and/or recommendations:----------------- -------------------------- ---- -.-•-•---------------------------------------L------- ---------------- ---------------- ---------------------------•-------...-----------------------------------.....-------------- -------------------------------------- -- -------------------------------------I------------- ------------.._.. ------------- ----------- ---- -------------------------- FINAL INSPECTION BY: /" . :------------ Date-_ - - -_--�� ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 120 Sycamore Street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press