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FOR OFFICE USE: -------------------------------- - ---- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ---------------------------------------------- ---------- (Complete in Duplicate) �10 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 LOCATION-..Zl�` -- ' -I ',- Owner's-N e __FZ--- Lr/ =�L�C _... Phone -------------------------------- Address. ---------2.��J d .�-.." ° ---•----- - - ----------_____1-••-------- Contractor's Name -- -- -- ----- _. ------ Phone Installation will serve: Residence Apartment House (] Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: --- Number of bedrooms ____L_ Number of baths ---/__ Lot size ----------- ------------------------------------- Water Supply: Public system ❑ Community system ❑ Private [(Depth to Water Table .5- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�( Hardpan ❑ Previous Application Made: (if yes,date........... ---------) No%L_ New Construction: Yes ❑ No, ,FHA/VA. Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic`T Distance from nearest well-----------------Distance from foundation--------------------Material_______.-___._.______-------_---------------___-. iNo. of compartments---- -------- ------ ----Size.----------------------- ------Liquid de th---------------- ---.-----Capacity--•-------- is o�Feea . Distance from nearest ell___ _._._:Distance from foundation___-- -- ___.Distance to nearest lot line_ ____ -------- I t zr Number of lines__-._______K- _��---..__ Length of each line___________ __C�_-__,_____.Width of french----- � Type,of,filter material____�)_VtA Depth of filter material _ ___f______Total length_______3_tri----_-------------------- ( ,egPi'tT Distance to nearest well------- 1-------Distance froo foundation______Il?._____.Distance t�o/nearest lot li e____- _._ I Number of pits---------f----------Lining material_ ,�l: e: Diameter__'tj�4A_1!C Depth-_.---_-�-r______.___.. O esspo Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------. ❑ Size: Diameter------ -------------------------------Depth---------------:----- --_--------------------------Liquid Capacity-----------------------------gals. N Priy' v — Distance'frorri nearest well ^__. _ .____"___" "'' :"' °`_Distance'from nearest buiding__=_� _��-_J�:-_---.__._=_. . F1 Distance to nearest ]of line-------------- `-----=--------------------s----------------------------------------------- ------------------------•---------------------- Remodeling and/or repairing (describe):. --res --=---------- ----�� - --------•------------- - - __- - --- ------- - --- yn-1 t� �_ 5 ----------- �� --------------------- { :J d-tyecerfify ---- ' fie' = --- -- __? ----------- -- -- ----------------- � I her that I have.prepared this application an that the work will be done in acc$rdance with San Joaquin County ordinances, Sta ws, and rales =reg' tions of the San Joaquin Local Health District. -- ----------- '------------------'------------------------------------------------------------ -------- -----------(Owner and/or Contractor (5igned)------y-- ---- - _ / ) B -=---- ----- -- ------------------------------------------------------------------------------(Title)----------------------------------------- (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 APPLICATIONACCEPTED BY------------ '------------------------------------ ------ ---------------------------------------- DATE------------------------------------------------------------ REVIEWEDBY------------------------------------------------- ------------------------------- ------------------------------------------ DATE-------------------------------------.. BUILDINGPERMIT ISSUED----------------------------------- --------------------------- ------ DATE-------------------•----------------------- -------------- Alterationsand/or recommendations- -------- -------------- ------ -------------=----------------------------------------------•------------------------------------------------ ---------- ---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ----------------------------- ------------------------------------ -----------=------------- -----�----------- ------------- ------------------ -------------------------------------- -------- ------------ -------- -- -- ------------------------------------------------------------------------------------------ ---------.------------------------- FINAL INSPECTION BY-- -- --------- ------------ Date ... - ------ ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Kaselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 P,P.CC. r s'`