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FOROFFIC�USE:----------------------------------------------------------- y. • ______.._________________---------_-__--_-_-_________- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ---------------- (Complete in Duplicate) ------------------------------- ..--.....- This Permit Expires 1 Year From Date Issued Data Issued F 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. JOB ADDRESS AND LOCATION---•- --------- Owner's Na - --------------- - ----------------------------- -------- Phone ------------------------------------ Address _ G 3 ---------------------------- Contractor's Name - ..,6r,r - ----------- --"" , Phone.. Installation will serve: Residence [Apartment, House ❑�',Commercial E] Trailer Court ❑ Motel E] Other ❑ Number of living units: Number of bedrooms __-� Number of baths J___ 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 M—< Previous Application Made: (If yes,date.....----------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tank: Distan`ce from nearest ❑ No. of compartments-------------------------Size-----••-------------------------Liquid depth---------------- ---------Capacity----------------------- Dispos field: Distance from nearest well------ - ._.Distance from foundation-----4.0---- ___-Distance to nearest lot line.---S'__-_____- Number of lines---------1----------- -'---'-' Length of each line----/Q_ci-'._____ -----Width of french-------A----------------------- Type of filter material_______-._.__Depth of filter material__. _!_"____-_.Total length______ __'---------------------- See pa Pit: Distance to nearest well _� ___.__ _-�Q ,_Distance from foundation_ _P.__.._____.Distance,#o nearest lot line_`j ______-.. Number of pits------j-------------Lining material-----55`_-�___._Size: Diameter______ ._3 Depth__-a-S--------------------- Cesspool: Distance from nearest well-----------------Distance from foundation..._...-___---------Lining material._-_---_--___________-____-_--_.__ ❑ Size: Diameter--------------------- ----------------Depth------------- -------------------------------------Liquid Capacity ---------------gals. Privy: Distance from"hearest well-----------------------------------_------------Distance from nearest building------------- ------------------____---_. ❑ Distance to nearest lot 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, St ws, and rules and regulations of the San Joaquin Local Health District. (Signe ---- - -- --- - nd/or Contractor) Y -- --------------I- ----- - - (Title) (Plot plan, Set size of lot, Io ;ion of s tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - -_.. � _l�r/'` --------------- ------------------------------- DATE-- " REVIEWEDBY---------------------------------------- ---- ------------------- ----------------------------------------------------------- DATE------- ++ 1 BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------------------------- --------------------------------- Alterations and/or recommendations------------------------------------------------------------------------------------------------•----•---------------- - -•-------------------------- --------------------------------------- ------------------------------- -------------------------------------------------------------- ------------------------------ ------------••------------ ------------------------------------------------------ ------------------_---------- ---------------------------------------------------------------1-------------------------------- -------------------------- -- - ----------------------------------------- - ------------------------ ---- ----------------------------------------------- ---------------------1-1 -----------------------•---•----------------- _ ^ FINAL INSPECTION Date-e.-------"--------- 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.