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FOR OFFICE USE; ------------------------------------------------------- -- APPLICATION FOR SANITATION PERMIT Permit No. ....:.......... ...... --------------------------------- ------------ -------- (Complete in Duplicate) Date Issued -.-_---------------------------- This Permit Expires 1 Year From Date Issued 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfall the work herein described. This application is made in compliance with County Ordinance No. 549. 21Zi JOB ADDRESS AN OCATION---- �5�'7--: '�d�--------- .... ------- Owner's Name- �l�t.-��/- ---------------- -------- ---- Phone------------------------------------ Address aa'� ----------- - ------------- ----------------------- �{` --- Contractar's Name Phone Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/- Number of bedrooms ��-- Number of baths __/__ Lot size ___ _ ___ r _ _________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _11A ft. Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam L❑ Clay Loam El Clay [:] Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date--..................) No ❑ New Construction: Yes ❑ No X FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �pti c�Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material-------------------------- _________------_____. No. of compartments-------------- -----------Size--------------------------------Liquid depth--------------------------Capacity...--------------- f Disposal Oield: Distance from nearest well -'_Distance from foundation____l.l'-..____.Distance to nearest lot line___________ X Number of lines------Z---------_ Length of each line-----`--"---------------Width of trench-------_��'��-------------- .- Type of filter m, Depth of filter material-----12_--------Total length---------I--,' _`_______________________ 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__._.-____________-------__-____.__. ❑ Size: Diameter- ------------------------- ----------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------.---------------------------.._. ❑ Distance to nearest lot line------------- ----------------------- ----------------------------------------------------------------- --------------------------------- Remodelingand/or repairing (describe):------------------------------------- - ---------------------------------------------------------------------------------------------•--•---------------- ------------ -------------------•------------------------------------------------------------•--•-------------•------------------------------------------- ------------------------ ------------------------------------------- --------------------------------------------------•----------------------------------------------------------------------------------------------- --------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e laws, and rules andegulations of the San Joaquin Local Health District. k (O eSi (Signed) - ---- -- ------ nr and/or Contractor) By:--------------------- --------------------------------- - - ------- ---- ----------------------)Title) �d (Plot plan, showing size of lot, location of system in� to well , buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ----- -- ----- --------------------------------------------- ----- DATE 3r��=�1i7----------------------------- REVIEWEDBY------------------------ - --------------------- ------- -----------• DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------- --------------------- -------------------------------------------- DATE------------------------------ ------------------------------ Alterationsand/or recommendations.------- ------------------------- ------ ---------------------------------------------------------------------------------------•---------------------- .----•-----------------------•- ----------------------------------------- ------- -------------------------------------------- , 1 -/v `~� t FINAL INSPECTION BY:......�. �-�------- ------ Date---------------3------- --- ----------------- ------------- 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.Cu.