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FOROFFICE USE: ^^ -------------------=------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...1. - - ------ ----------------------- ------------7--------------- (Complete in Duplicate) _ / -.--- 'This Permit Expires 1 Year From Date Issued ~ Date'Issued `�`J.�. r 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. /J •. Z3�-2e _-Y,3 JOB ADDRESS AND CATION___ -. . ? �4 ��t ----------------- Owner's Name------- --- ••_ - �.. _W�. Address------ 1J7 _ -_..__. -- ----------------•----------------------- Contractor's Name----------•- -• -- ----------------•------------ •--- Phone -------•- •-- ------------ -------- Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel Other ❑ Number of living units:.______ Number of bedrooms ___! Number of baths __ _ Lot size -________/-------�___-------------------- Wafer _______ ___ - - -------------- Water Supply: Public'system ❑ Community system ❑ Private xDepth to Water Table ._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay-Loarn ❑ Clay ❑ Aclobek Hardpan Previous Application Made: (If yes,date--------------------) No New Construction: YesNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: `' V1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - -� - 4pisposal �ic T n ' r Distance from nearest well_________________Distance from foundation__._____-_______-.Material____________.._ No. of compartments------------------- ------Size--------------------------------Liquid depth----------------- Ca pacify--..---------- ipFiel Distance from nearest welL._,�^Y -Distance from foundation_ ___._.Distance tonearest lot line__-��`' ___.. Number of Fines-------- Length of each,hne_��.. S_'"_ O Width of trench.-__-„�_ 01 Type 1 t9 -- Type.of filter.material—S- . __._____ . _Depth of filter material----r_81------------Total length-___-ZACQ-�" Seepage Pit: Distance to nearest well----------------------Distance from foundation------------......Distance to nearest lot line--------______.__ ❑ Number of pits---------------------Lining material_----------------------Size: Diameter------------------------Depth----------------------: --------- I Cesspool: Distance from nearest well-----------------Distance from foundation._.._-----__-`_____.Lining material----------------------_--- ______.___. ❑ Size: Diameter--------------------------------------De th------------------ p ---- - ---------------- ------Liquid Capacity-- -- ----------------•---gals. .. _ _. Privy: Distance.from nearest well__________ ___T---------- ----_-----""__----- _Distance;from.nearest,building_--___.____-_-----_--___-----______--. b ❑ Distance to nearest lot line -- ------------------------------------------- ------------- -------------------------------------- 1E Remodeling and/or repairing (describe):--- --- = ---------------------- ------------------------ yf ---------------•----_----------------------------------------------•----------F---•-------------------- -------------- --- ----------------------------------------------------•----•----------------------------------------------.------------------------------------------------------------------------------------------------------------------ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------•--------------------------------------------------------------------- ----' ;i -----------------------------------------------------(Owner and/or Contractor) BY:----------------------------------------------------------------------------------------- ------------------------------------------(Title)-------------------------------- ----- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc., can be placed on reverse.side).. r ; FOR DEPARTMENT USE ONLY --------------------------- APPLICATION ACCEPTED BY-- ------------------------------ -- ---- ----------- --------------------------- ---------- TE------------------ REVIEWED BY ------- ----- A - - BUILDING PERMfT ISSUED___________________________ -_____ _ _ __. __ - -- -------------•-------- --- Alterations and/or recommendations:--------------"_...._ -- ----#.x --- -- ---- --------- @ = ------------• - FINAL INSPECTION BY-------- ------- --------------------- Date-----------------`_-..-�%+� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 west 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISE(? 6.59 3M 3-'63 F.F.gp. ' 4