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FOR OFFICE USE: ----- ---------------- ----- ----------------------- - - --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. a.2 --••- --------------------------- (Complete in Duplicate) -------------------------------- _ This Permit Expires 1 Year From Date Issued G��" Date Issued _7=Z - J 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. K9. 1 JOB ADDRESS AND OCATIONf �1--------------- ----- Owner's Name------- ---•---- -- ------------------ Phone. Address--••-•------ _- •---- --------------1--•=�-1---------- -- -------------- ------------------------------ ----------------------------------- l ' Contractor's Name----- -----------•- �f�'---C_-------- ? Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. -__ Number of bedrooms _2Number o baths __/___ Lot size - ---------------------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table ._.__ _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑: rpt Previous Application Made: (If yes,date.___..__..__..__--1 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 Tank: Distance from nearest well_________________Distance from foundation--------------------Material______.____-_________.__--_--__-_________.._.._- ❑ No. of compartments--------------------------Size--------------------------------Liquid dep h----------------- --------Capacity----------------------- Dispos Field: Distance from nearest well----.j'4----- Distance from foundation___.!- -----Distance to nearest lot line--S.. ...... Number of lines-------/-------------------------Length of each line-------1-0 D------------.Width of trench_,;��-- Type of filter material____:-- --�.------Depth of filter material.__.__) ..............Total length-----IV d_________________________._ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------- --____._ ❑ plumber of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---- ---------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material....____.._.---_.._.__._____.__.__. E] Size: Diameter------------------------- - -------Depth------- --------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------ ------------------- ---------------------Distance from nearest building---------------------------------------._. ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-----, 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. ----------- -------- -----------------------------------------------------------------._. r and/or Contractor (Signed) / lI�Y+ � )Title)- ---- - ------------ -- -------------- gY=--•--------------- - • --------------------------- - - --------------- ---------------------------------------- ------- - --------------- (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 r� APPLICATION ACCEPTED BY--!"� -------------------------------------------------- DATE_..--{-- -N77_7 j--- REVIEWEDBY----------------------------------------- --- ---------------------------------------------------------------------------•--- DATE.----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------- ---------------------------------- ---------------------------- ------ DATE.----------------------------------------------------------- Alterationsand/or recommendations------------------- ------- ----------------------------------------------------•---------------•-•------------------------------------------------------------- ------- --------------------------------------------- ---- ------------------ ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- ------------------------------------------------------- -------------------- ------------------------_----------------------------------- - FINAL INSPECTION BY:.." ----------------- Date--* ...........---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.