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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 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 CATION- ------,/ lsa ------------- p_ _ Phone-----•----------'-l--- Q' Owner's NamePW_4�1�f� t ----- -- -- Address------------/Z,/ - `Js------ �/v U F��' ---------- ._ ------------------------------ Contractor's Name------- --•------------------------------------ Phone-------------------••- Installation will serve: Residence ❑ Apartment House [] Commercial ❑ Trailer Court )] Motel ❑ Other ❑ Number of living units: ___`__ Number of bedrooms __Number of baths __l--- Lot size -____l __________________ 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 lay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,dote----------- -----) No 3"� New Construction: Yes ❑ No [ "'FHA/VA: Yes ❑ No [�t'' 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----------------- El Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------:--------------------- \ Type of filter material-------------------------Depth of filter material.----------------------Total length------------------------------------------ -- __-__- C1� Pit: Distance to nearest well__.-------Distance fro found tion_,��__�_____-Distancce to nearest lot line__._----------- Seepage --2- Number of pits.---j-------------Lining material__Oe 7e: Diameter___ ---------Depth____�.r______________ F` Cesspool: Distance from nearest well--------------_Distance from foundation-- ------------------Lining material-_-"________________-__-___-_________ v ❑ 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):__ ___ ___________________ -------------------------------------------------- _ -- --------------------_::_:::_::::______=_::::__:::::_:_ - ---- --- ------------------------------------------------------------------------------- --------------------------------"----------------------------------------- ------------------------------------------" I hereby certify that I have prepared this application anroaquin work will be done in accordance with San Joaquin County ordinances, State laws, and les and regulations of the ocal Health District. (Signed) � �-5�----I--------------- li —� wrier d/or Contractor) By:----------- ---- ------ ----- ------ - ------------------------------------ ----------------------------------------------(Title- ------ -- ' ----- ------------- -------------- (Plot plan, showing size of lot, loc on of system in relation to wells, buildings, etc., can be placed on reverse side), FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY /�; r'2 — DATE - -----�---------- - REVIEWEDBY------------------------------ - - ---------- .----------------- ------------------------------------------ DATE------------------------=---------------------------------- BUILDING PERMIT ISSUED----------------------------- - ------ AT E--------------------------------------------------------------- Alterations and/or recommendations:______-_____�l.- S _ <_-_-_- _ -� � - --- --��--------------------------- -•------------ ---------------- ---------------------------------------------- --------------- ------- -------------------------------------•------------------ ---------------------------------------------------•-- ------------------°--------------------------------------------------- - ---------- -------------------------------------------------- ---------------------------------------------------------------------------------•--- y1" - - -- ----- -------------------------------------------------------------------------------------------------------------------------------------- -- --- -------- FINAL INSPECTION BY------------ ----`-- __ /�� ---- ------ -------- ------- -- Date------------------- - - -" --- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:Rozelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California Lodi,California Manteca,California Tracy,California F.R CC. 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