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FOR OFFICE USE: `T(t a 10 W J*j L - 4 ------ ---------------------------------------------- ---____________________________________-_.--_. 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 ' w herein described. This application is made in compliance with County rdinance o. 549. - io JOB ADDRESS AND LOCATI N ------ --------- --------------- - --------------------------------- ............................. Owner's Name---------- l�- �J ------------------------------ --- - ---- Phone.................................... Contractor's Name--------------------------- ----------------- ---------------------------- ------------- -------------. Phone----------------------------------- s, k Installation will serve: Residence [Apartment House ❑ Commercial E] Trailer Court E] Motel ❑ Other E]r Number of living units: -------- Number of bedrooms _ Number of baths -------- Lot size ___________________________ Water Supply: Public system ❑ Community system FT'-Private ❑ Depth to Water Table _lyft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 2--clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-----------,___:__) No Er New Construction: Yes [5--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 Ta k: Distance from nearest welIA04-�__Distannce f;om fo��n_��------------Materi�JA No. of compartments__.----02._- .............Size,[_p..� Liquid depth___*,1_�__�------------Capacity-.1OT___._-- Disposal field: Distance from nearest Vel_f .?�.Distance from foundatjW__v��,.___ Distance to nearest lot line__.e_ _ _______ Q� Number of lines-------------- --------------- 'ys ------ ----_ ength of each --.-----_--.----------------- idth of trench-----�r__------._---.--- ------ Type of filter mate ria L�, __ .G--_Depth of filter materiaL__._?F'__________Total length________,l ___________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation___--___-_.-__-___.Distance to nearest lot line__..__--__--_--- 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. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F] _.__--___-___-____-_______--.❑ Distance to nearest lot line-------------------------- ------------------ ---------------------- Remodeling'and/or --------------------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, State laws, and ru s and regulations of t1w San Joaquin Local Health District. (Signed)------------------------ -----------------------------------------------------------------(Owner and/or Contractor) B (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----------------------------- REVIEWEDBY--------------------------------------------------------- -------------------------- -------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------- ------------------- - Alterations and/or recommendations-------------------------------------- ----------..----------------------------------•----------•----------------_--------•----------------- ----------------- - - ---------- FINAL INSPECTION BY:----------- ----- -----'_ <. �'- -� Date---- ------- SAN --- /SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC. %t F _