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t FOR OFFICE U-- V - -- E --�3------ " � --.� --=---- � - _--_----_ ____________________________ APPLICATION FOR SANITATION PERMIT Permit No. ..l...........�7�.. - -- ------- ----- ---------------------- (Complete in Duplicate) --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued i 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 549 r le JOB ADDRESS AND LOCATIONf �---------------------------------•------------..._._-•-- ------------------------- Owner's Name----- -Y-- -_/1 /--------- -.,� e../ ��lD----------- -- - - ------------------------ -------- Phone.................................... Address elel 1 ; ---------------------•---•------------------------------------------------------ Contractor's Name----------------------�- - _- ------------- �' "� --------------------..__.. Phone.-----•`•� ....--r-� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/_ Number of bedrooms 3___ Number of baths/----- Lot size --- 5 ___�_d----------------- Water Supply: Public:system Community system ❑ Private ❑ Depth to Water TableS7._ ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa;�ew y am E] Clay Loam E] Clay El Adobe ardpan ❑ Previous Application Made: (If yes,date------------------ -} No 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material---.__---..----.--..-----.---------__._--..___._ ❑ No. of compartments--------------------------Size.--------------------------------Liquid depth--------------------------Capacity----------- Disposal Field: Distance from nearest well---------------_-Distance from foundation-/d7--- ...._.Distance to nearest lot line.._--__-----_ Length of each linet? ..f:s,____--Width of trench..- ------- ---------- +� � -- -- ---- ---------- g � -Total length----�.� Oa Type of filter mafierial__r:�`PG� Depth of filter material__j_�-__- Num er of lines______._. __ _ _ I� Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------------------ — F-1Number of pits------------ ---Lining material-----------------------Size: Diameter--------------.--.-_. -Depth--------------------------------- Cesspool: Distance from nearest well_________________ Distance from foundation------------------_.Lining material_---------------------------------- ❑ Size: Diameter------------------°------------------Depth----------------------------------------------- a Liquid Capacity------------•----------- gals.; Privy: distance from nearest.well----------------=----------------------------------- from nearestrbuildin d f g------------------------------------------- ❑ Distance to nearest lot line------------------------------------------------------------------------------------�'------ Remcdel'stig and/or repairing (describe)------------------ -- ---------- 4-------------- --------------•----------------------------------------- -v t ----------------------------------------------------------------------------------------------------•--•---------------------•-----•------------------------•--_---------------------------•----------------------------- ---------------------------- ---------------------------------------------------------- ki I hereby certify that Ljave prepare this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, cl ul s and gu ti ns of the San Joaquin Local Health District: ,. �- ----- --------(Owner and/or Contractor) (Signed)----------- ----------------------------------------------- 696 By:-----------------------------------.— ---- ----- .1Y' ------ ---------------{Title)-- = ---------------- {Plo+ plan, showing size of lot, location of.system in relation to wells, buildings, etc., can be placed on.reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-. _p DATE---------- -------------------------- REVIEWED BY =--------------------------------~'--------------_- DP:ATE-:--- r BUILDING PERMIT ISSUED---------- ----------------------- '- ------------------------------------- = --`- ------ DATE_-4-----, ------------------- - --------------- Alterations and/or recommendations:_--:---------- ------------------------------------------- ----------------------" ---------- --------------------------------- ----------------:----------•----------------------------•-- ------------------------------------------------------------------------------------ --"------- -=---------------------------------- ---•-------- --------------------------------------- ' ---------------- -------------- ------ ----- ---------- ------------------------ - ------ ---"------------------------------ ------------------------------------ --------=--------------------------------- ----------=-------- FINAL INSPECTION BY: Z ---------- Date---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 R£Vf9£P B•59 3M 3-'63 F.P.CO. >