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FOR OFFICE USE: i^ LA --------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. __,� ._...... . = (Complete in Duplicate) Date Issued _ Application is hereby made to the I� This Permit Expires 1 Year From Date Issued -------- pp y 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. p0,5 l Z-z 37v'6: A .' CC . JOB ADDRESS AND LOCATION':;.1, V, -__--•- ----- P _.' It - - -- ------------ ---- '`-- - '`"' -- - --- - Owner's Name xa --------------------------------------------------- ------- Phone ".. - Address--_----------------- ------ '"Y --------------------------------=------------------ --•-- - Contractor's Name__. -± "'=--------------•--•---------- = -- Phone. Installation will serve: Residence j] Apartment House ❑ Commercial le Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _h___ Number of bedrooms __ ___ Number of baths _ ____,Lot size 122_ -17-d----------•----------------------___.___ 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 q] Clay ❑ Adobe❑ Hardpan [ Previous Application Made: (If yes,date-------- -_..__) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool'permitted if public sewer is available within 200 feet.) j Septic Tank: Distance from nearest well_43p---------DistanF from foundation_fa------------.Material__ _�__ ____________________________ 6� [ No. of compartments---A---------------_ _0,r11?_tT----- -• Liquid depth-------------- ---Size- ---...-=- -- - -------- CapacitY-- ---V'l--------- Disposal - -Disposal Field: Distance from nearest well..,f_4----------Distance from foundafion_lP'-----------Distance to nearest lot line________._____ [ ] Number of lines-------1-------- -------- --j Length of each line----- ---------•-----Width of trench--- y-�`_-----_----------:---- Type of filter material __ ( --_Depth of filter material_____ ___ ---__.Total length_Ily•f�_'______________________________ Seepage Pit: Distance to nearest well_-/,ems------------Distance from foundation_,'-P'___.._.___.Distance to nearest lot line_s ------------- [] Number of Its____ _ ---Linin material/_Wr- .________--Size: Diameter___ op.`........Depth_-_ -,r---------------------- ; i� Cesspool: Distance frominearest well-----------------Distance from foundation--------------------Lining material-._.________________--_-___.________-. ❑ Size: Diameter ------- ----Depth------- ------------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from;nearest well-- ---_------------------------------------------Distance from nearest building---------------------------------.......... [] Distance to nearest lot line--------- ------------------ ---------------=--------------------------------------------------------------- ---------------------------- Remodeling -------------------------Remodeling and/or repairing (describe):---•-------------------------------------------------•-----------------------------•----------- ---------------------------------------------------- --------------•--------•------------------------------------------------•------------ ------------------------•--------------•------------------------------------------------------- - ---------------------------------------------•--------------------- -------------------------- ----------------- ---- ----------- --------------•----------------- ----------------------------------------------------------------------------------------------------- I herebcerti that ay re are f s application and at he work will be done in accordance with San Joaquin County ordinances, Sta laws nd r s d .r g a i the Sa oa Local Health District. (Signed)- - -------------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------.------------------- ---- ----------- ---------------------------------------------(Title)-------------------------------- ----------- - ----------------- (Plot plan, showing size of lot, location of system in Ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- .: -------------------- ----- r- --- -------------------------- REVIEWED BY-------------------------------- ------------ ------------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------= ------ ---------------------------------------------------------------------------------- DATE-------------------------------------------------------•----- Alterationsand/or recommendations:--------------------------------------- - ----------------------------------------------------------------•------•- -----------•- ----------------------------- Is -------------------------------•----- i I! 5 FINAL INSPECTION BY:..,y ----------------- ---------- Date--- ". ------- ------------ - ------------------------------------ il SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haiellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street ? Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEP 8-59 3M 3-163