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FOR OFFICE USE: ------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ---------- ------------------------------------ ---- --------------- (Complete in Duplicate) Date Issued 3_`.-'�� --------------------_-----------_----------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for e permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION----- d - -- ----•------ ------------------------------------------------------------------------•------------------- i Owner's Name_ __ ---- --- --- - - ------��------- �""---------------------- - --------------------- - -- ---------- Phone----------------------••------------ � /�� Address--.- -- I Contractor's Name--------_-- Phone_`�� G`3/� I Installation will serve: Residence Department House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _J/-. Number of bedrooms --5P77 Number of baths __/_ Lot size ______ _________________________________________________ Water Supply: Public system ElCommunity system [IPrivate Depth to Water Table Y0 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 [SHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Distance from nearest well-----------------Distance from foundation--------.-----------Material-___.--_-_._._._____._-------------------------- . No. of compartments--------------------------Size--------------------------------Liquid depth.-------------------------Capacity--.------------- ----- e DisposalField: Distance from nearest well-,T-O------Distance from foundation_ _ S____._._Distance to nearest lot line___S______- L7 �%- y i Number of lines...-.__�__________________.. __ Length of each line_____�d______. -----.-.Width of trench_-___ .y__________ --------- Type ___.___.Type of filter materials5or_RQ 4 _-/V -Depth of filter material__ _ -- ------Total length___________________5 ------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearestlot line----------------- _V ❑ Number of pits----------------------Lining material----------.-----_ ---Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- e" ❑ Size: Diameter----- -------------------------------Depth------------------------------------------------ ---Liquid Capacity------------------ ---------gals. 0 I Privy: Distance from nearest well______ ________________-.-_-__-__..._.._____Distance from nearest building--,.------------------------------------._. ❑ Distance to nearest lot line-------------- -----------------------•--- --- ------------------------------------------------------------------------------------------------ Remodeling and/or repairing {describe):----7_-- ----- ------�? ... ------ )t-------- -------- ---------�. ------------------------------------ -----------------------------------------•---------------------------------------------------------------------------------- ---- ------- ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tfateaws, and rules nd re lations o� San oaquin Local Health District. --------------- - ---------------------- ------ - --------------- ------ -------- Owner and/or Contractor [Signed) { ---- By: ----- --------- ------(Title)- (Plot plan, showing size of lot, location of system in relation to wells, dings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- .- ._._._ .-' ---------- - ---'� -- --��-� DATE 6 ------------------- REVIEWEDBY----- ---------------------------------- --- --- ---------------------,--------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED.-------------------------------------------------------------—---------------------------- --------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------ --------------- -- ----------------------------------------------- -------------------------------••-------•------------------------------- ------------------------------•-------------------•----------------------- - --------- --------------- ---------------------- ------------------------------------- ------------------- ------------------- ------------------------------------------------------ --------------------------------------------------------------------•- ----------------- --------------------------------------------------------/----------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- FINAL INSPECTION BY:------(� --------------------- -- ------------ Date------------------ rte- ------------------------------------- .. .. .. - 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.C C.