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f FOR OFFICE USE: /yy ----- ----- -----------------_--__----------------_-__-. APPLICATION FOR SANITATION PERMIT Permit No. ..a ---------- (Complete in Duplicate) !�=� --------------------- This Permit Expires i Year From Date Issued 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. 4r JOB ADDRESS AND LO ATION---------------— - ----------- / 1-------------------- ------ C� Owner's Flame------------ -------- - ---- -------- ---------------------------------- ---------- Phone------------------------------------ Address- 11` --- .'.._ - k ----"/ • Contractor's Name--------------- -------------------------•--------------------------------- •--•------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Cb`mmerc al ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms _'?�__ Number of baths ' _ Lot size __`_-l ._ __ _________________- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table {lO_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay LoamjK—Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No N — New Construction: Yes'k§�No ❑ FHA/VA: Yes ❑ No T — TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public 7wer is available within 200 feet.) ` Septic Tank: Distance from nearest wekl_.qf'_�istance from foundation------`0_.�4.Mat�eJ ial_rr_ -_____________________ No. of compartments--------->�---------Size--- Liquid depth---___J . ..........Capacity___1 Dispos Field: Distance from nearest well. , -�Distance from foundation___I .- .-tDistance to nearest lot line..... / l/ Number of lines-------------- _........ __ Length of each line._1611�__�6��.Width of trench-------- ------------------ ----- _______..________ Type of filter material-- � _.__Depth of filter material--- ------- length_.__.__1'_�_a--------------------- 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------------------------------------- F1 Size: Diameter------ - -----------------------------Depth----------------------------- --------------------_Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well--------------------------_--------_--------__.-Distance from nearest building----------------------------------------- F1 --- -.❑ Distance to nearest lot Iine--------------------------------------------- - ---------------------•- -------------- ---------------------------------------- - ------------ 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 rules and regulations of the San Joaquin Local Health District. (Signed --- ---- -- ------ ------------------------ - Owner and/or Contractor) SY• ------------------------------------------------------------(Title)-------------------------------------------- - ----- (Piot plan, showing ze 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-- / ' 1�---------------------- REVIEWEDBY------------------------------------ ------ -------------------------------------- -------------- --------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------- ------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---------------------- ----------- -- - - ---- ------------------------------------------------•-•-------------------------------------------- --------------- --------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ --•-•-•-------------•-------------I------- --------------------------------------------------------------------------------------------------------------------------- ----------------- -----•--------------------------------------------------------------------------------------- ----------------------- ---•-------------------------------------------------------------- - -------------------------------- ---------------------------------------------------------�-- ------------------------------ ----- ------------------------------------------------------ -------`-------------- --------------------------------------------- FINAL INSPECTION BY:. ..c Date - - f Z -f�---------------------------- 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.CO.