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FOR OFFICE USE: 579 z -------------------------------- ---------- APPLICATION FOR SANITATION PERMIT Permit No. -- .../ -.. ----- ----------------------------------- ---- ------- (Complete in Duplicate) --------___ This Permit Expires 1 Year From Date Issued Date Issued -- --� Q 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 o. 549. �f JOB ADDRESS AND LOCATION---------1---.._<-----------.�:-a-7-.,-�,y!'----------------- -.ft.-�•: --------- Owner's Name----------- -------�/fi ------ !��,r :R=_�-------------------------- ----------- ---------- Phone------------------------------------ - - --- - Address--------------- ---`-•�-=---------y-`-`�------:�-- a- _� r; ----•- Contractor's Name------ =-----------------•-----------'------------------ ---------- -------------------•---•-------------- ------ Phone-----------.------ -------•-------- ' Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El l Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size --- ------------ - -------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ e 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.) Septic Tank: Distance from nearest well--------------_-Distance from foundation--------------------Material--------------_-------------.------------.-----. ❑ No. of compartments--------------------------Size-------------------------------.Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well-------------....Distance from foundation--------------------Distance to nearest lot line----------------- 1771 Number of lines-----------------------------------Length of each line------------ ----------------.Width of french--------------.------------------.-- Type of filter material------------------------- of filfer material ___.___--_-__--..'.Total length-----------------.--._ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest loft line----------------- F-I Number of pits----------------------Lining material-----------------------Size: Diameter------------------.----Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materiai---------- -----.--.--_-.---.----_-- r ❑ Size: Diameter----------------- - - -------- ------Depth---------------------------------- -----------------Liquid Capacify---------------------- -----gals. 3 Privy: Distance from nearest --�__�__-----------------Distance from nearest building-.-/! -1-' Distance to nearest lot line.-.----- -- -- Remodeling and/or repairing (describe ` ----F�`- _ �'I =J= ------ rte u .rte:✓ / l 4 -----------------------------------------�-7------------------_----_--------••---------------•---•__---------------------------------_---------------------•--------..----.-----------------------------.-----------__._--.- \S --------------------------------------------- --------------•--------------------------------------------------------------------------------•-------------------------------------------------------------------.------------ 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 I BY: --- r 1--•----�- -•------------------------------------------------------------------------------------ ---(Title)---------- ---- A -- (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 i 1g------------ ---------------------------- DATE---�--- ------ ----- ------------- REVIEWEDBY------------------- ---- --------------- ------------------------------------- --•---- ------------------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------ ----------------------------------------------- --------------------------------- DATE----------------------------------------------------- ------- Alterations and/or recommendations:-------------- ------ ----------------------------------------------•------------------••--•-----•----------------------------------- ----------------------- ----------------------------- ---------------- ----- ------------------------ ------------------------------------------------------------ -•------------------------------- ------ ----------------- -----•----------- ------------------------------- ---------------------------------- ------------------------------ -------------------------------------------------------------------------------------------------------- --------------------------- ------- --------------------------- ------------------------------------------------ ---------- - ,�� r FINAL INSPECTION ------ --- --- ter-.---------- Date- —/;�P--—4�7.....---------- --- - -- - -- ------- ------------- 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.00.