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FOR OFFICE USE: ------------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . ------------------------- ---- -------------------------- {Complete in Duplicate) • �?/� -_ -- ___.___ . This Permit Ex ires 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, JOB ADDRESS AND LO ATION.._!'"� '�C, - • Q Owner's Name ._ f ------ Phone------------------- ---------- --•-•-- Address_.____.... .. // ' l..,?� - -------------------------------- . --------------------- •- Contractor's Name---------- _ -- Phone-----------------------_--_--- Installation will serve: Residence Apartment House ❑ CommerciiiI ,❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '____- Number of bedrooms _ =± Number cf baths __'-.._. Lot size ____I'�______•- .............. a W t r Tabl «�� Water Supply: Public system ❑ Community system ❑ Prrvate� Depth to a e e Character of soil to a depth of 3 feet: Sand [-] Gravel [:] Sandy Loam E] Clay Loam E] Clay ❑ Adobe Hardpan El Previous Application Made: (If yes,date----------- - --) NoA New Construction:` Yes 9 No ❑ PHA/VA: Yes ❑ No TYPE OF INSTALLATION'AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) Septic-Tank-:—.; w-Distance-from,nearest-well_ b_ Distance4from-foundation- _ No. of compartments-'A-_----- _-----Size__t??.X - -- ------Liquid depth-.----�.--�i ------Capacity-----_�_ Disposal Field: Distance from nearest well __7_d_------Distance from foundation...j,.V_l-------Distance to nearest lot liy..4.......... J Number of lines_.... t..___*�- Length of each line---/740__-'.. ? Width of trench____�40,__�________________ .1 Type of filter material__I___ Depth of filter material_ '_-r'� ,.Total Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------------_..Distance to nearest lot line______._________• „Q ❑ Number of pits----------------------Lining material--------.-------------Size: Diameter__-------------------Depth--------..------..------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___.____-.--_______________________-_. • ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------.Liquid Capacit ------------_-------------gals. .,,�wr��.�a:..:f�'-.' -n �r-rora,.--..e...•-•;�7R..Fas>:Y,e."� - •.,,... - -..-,�,—,«,..._.��.� �-,a,.�„`:-.. --” -'� .—..-:..:�.��r-- Privy: Distance from nearest well__,^____________________ ------- ------. . _Distance from nearest building___-__-_____-_•-•--_-_-_ .--------- t ❑, Distance o nearest loft line t � dI Remodeling and/or repairing (describe):----- ----------- �'�"ri.` ---------------------------------------------- 70 t .._... - -!----•-------•----------------------------------•---•--•----------------------- -------•-- •-------------------------------------•------------------..---------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------......----------------•-------•-•--•-----••-----••-------•------------•-•-------------..------••---------,._..------------------- I rhereby certify that I have prepared Is kation and hat the work will be done in accordance with San Joaquin County ordinances, State laws, an rules n ula ' ns f the n oaqul Local Health District. [Signed)--- ---- -------- ----- --- - --- ---------- ------ --- -----(Owner and/or Contractor( By:------------------- -----------------------------------------------------------------------------------------------------------•----(Title)---------------------------------- (Plot plan, showin ae 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.- -- .�- 4 ;;;--- BUILDING PERMIT ISSUED----... --------- DATE-------- -------- -------------------------------------- Alterations and/or recommendations:. -------------•...----------------------•-----------...-------------------------------------------------------------------------- ---------------------------------------- ----------- ------••-•------------- -I----------------- ---------------------------------------•-------------------------------------------------------•---------------------------- -------------------------------------------------•----...•--•----------------------------------------------------__..........-_.•• ------------------------------------------------------------...----•------------------- ----------------------------------------------------------------------------- -- -----------------------------------------•-----•--•-••••-------•---------------------------------------------------••------_-----•-------- FINAL-INSPECTION BY---------- -------------- -- Date Date-------- '^ ?.' -- -- ____-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California }{ ES-9 REVISED a-59 F,P.CD.2M B-BD