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FOR OFFICE------------------------------ - USE------------- � �� / � ----------------- -------------------- APPLICATION FOR SANITATION PERMIT Permit No. _____...-._------------- (Complete in Duplicate). .. , This Permit Expires 1 Year From Date — Date Issued -------.--,-•.-.,_-�� ----- - slued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wo efts descrbec This application is made in compliance with County Ordinance No. 549. . * jA)' ?1tL—Imo-SP JOB ADDRESS A LOCATI .'_ Owner's Name. -------------- ---------------------------------------------------------- ------ -- Phone------------------------------------- Address ---•-------=-------------- ••- --- � ^-� Address----= --------------------0- Installation = r`-'+---=-- d_-__-------- ----------- -------------- --------•• l / Contractor's Name------------ ` �' Phone will serve: Residence 2]/rApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms.. Number of baths Lot size . . /l-4 --------------------------------- ' Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Glay Loam 0 Clay ff Adobe [3 Hardpan ❑ Previous Application Made: (If yes,date_---.-__._,.-.:---..)._No_9;-'_'**.New Construction: Yes ?Er—No ❑ FHA/VA: Yes Z�— No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) J f Septic Tank: Distance from nearest wel .. 9_--._Dis#ante fro'm foundation...-.-.....Maier'`I ��/ ------ No. of compartments... N ----------------Sized-&- ----Liquid depth___4! .....-----Capacity.k��------ Di .. f tr spos�a�Id: Distance from near welL.��A.��... ��.__.Distance from foundation... .....--Distance to nearest lot line__��....... Number of lines------ r ength ofJ,each line----- 1 ..._ .Width of trench_,,Z--....�------._..-_----- ;. Type of filter material_ Depth of filter material---`-._------ ataE length _____________ 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...-----.-..-----------....-.._._... u Size: Diameter-- ----------------- ------ DePth-- --------- ------ - ------ ---------Liquid Capacity--------- r---�:--gals. C Privy: Distance from nearest well .... ..----f_. .... --------------------` Distance from nearest building----------------.-------....._----------- '1 ❑ Distance to nearest lot line-------- ------------- --------------------4 -------------------------------------- Remodeling and/or repairing (describe):------ --------------------- -------------------------- -----------------------•-------------------------•-------------------------------••--------------------•-------------------------•- ------------------------------------------------------------------------- --------------------------•------------------------------------------------------. ----------°-----------•--------------------------- ---•------------------------- --------------------------------------------------•-----_---------------------------------------------------------------------------- - -- 1 I'hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reguia+ions f the San Joaquin Local Health District. (Signed)------------ `� - --------------- ----- - ----- ---------- = { errd..or Contractor) By:--------------------------------------------------- —: - -- (Plot plan, showing size of to+, location of system ' ation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- ------------- --------------------------------------------------- DATE------ --------------------------------•----------------- REVIEWEDBY-------------------------- ----------------------- -------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------- -------------------------------------------------------------------- ----------------- DATE----------------- ------------------------------------------- Alterations and/or recommendations------------------------------------- --------------------------------------•----------------------------------------------..-..---• --- .............. ------------------•-------------- ----------------------------------------- ---------------------------------------- -------—----------------------I ._..------------.--------------------------.------------------------------------------.-......---------------------_------_--i_- .. r r rDate--- --FINAL INSPECTION BY:. .. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:elton Ave. '' 300 West Oak Street 124 Syearrrore Street 205 West 91h Street _. Stockton,California .,..■.,Lodi,California Manteca,California Tracy,California cs 9 REVISED a-59 3M 3-•63 r-mcn.