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FOR OFFICE USE: - -------------------=--------------------------------- - --- / ----------- --------------------------------- -- APPLICATION FOR SANITATION PERMIT Permit No. ..../ -- -------------- -------------------------------------- (Complete in Duplicate) __.___..__ This Permit Expires 1 Year From Date Issued Date Issued _____ _ 5 Application is hereby made to the San IJoaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. FE-,CA L-0 PJ JOB ADDRESS AND LOCATION__4 Peer-------- - -- --- --------- ` f I Il ./fid Owner's ----- / 1 ------ Phone__ --------=------------------- �� Il �# - - ------------------------------------------------------------------------- -----•---------------- Address..... -------- Cent ractor's Name_ ,a g� / f��1 -------..---•--------------- ----------------------- --------------------------- Installation will serve: Residefice [ tApApartment House ❑ Com"rcial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units:.__.,—Number-of-bedrooms-.��'_'_•:-Number of 'afhs __ .__ Lot size __ �'� - -- Water Supply: Public system ElCommunity system [-] Private Depth to Water Table -------- ft. Character of soil to a+depth of 3 feet: Sand ❑ Gravel ❑ = Sandy Loam ❑ Clay Loam © lay ❑ 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 ermitted,if pa6lic sewer"is available within 200 feet. Septic �: Distance from nearest,weil-, .t�__. __Distance from foundation__-/p_____-___.Material__. Tj_ A1e1a'e j_-5`�.._...__ No. of com artmerits_�_—��___._____Size__�_x_ Q `; Li uld de .th__-_._. -------------- -.Ca acit S---cfi------ Disposa field: Distance from nearest#wc-H __n-.._Distance from foundation... L=�_.------Distance to nearest lot l _________________ EY Number of lines___.____/_______ ____ ___ ______Length of each line....... ____._-.__---..Width of trench_..-------:_-_-...__..._____._ Type of filter material--- ��rG1�Depth of filter.materiaL____I_S----------Total length_____________ __ Seeps at: Distance to nearest f well_ --. .-.__-Distance frgm foundation-__._ _____.Distance to nearest lot line----------------- - /- Number of pits._.______-Lining material----1:!MW_ 1_&ize: Diameter__//)e_6lf2—r�epth--- Z—_.______._ Cesspool: Distance from nearest 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 and/or repairing (describe):_______________________ __ ' ---------------••------•-•----•-----------------------------------------------------------------------------------------------------------------------=-- - --------------------------------------------------------------------------•---------- ----------------------------------------------------•------------------------------ -----------------------------------------=------ - 1 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State la , d rule and regulations of the San Joaquin Local Health District. i (Signed)..---- ---- -- ---- --- --- -- --- ----- - -- -- ------------------------------------------------------------------- ----------------------(Owner and/or Contractor) is �. By:------------ ••----••-----------------•-----•----------------------- ------------------------------------------------------(Title}--- - �'��-------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,,etc., can be placed on �ev'erse side`}. �"" FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----. ------------------------- ---- --70 ��ii S�^--- --- -- ------•------------------------- DATE---------�- --- ------------------ - REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED---------------------------------------------------- -------------- ---------=-------------------------- DATE----------------- ------------ ----------------- Alterations and/or recommendafions:------------------------------- -------------------•-•-•--------_--------------------------------------------- ---------------------------------- --------------------------- ----------------------- - -- - ----------------- . ..--- FINAL INSPECTION--B _-= ------- ----- Date............. _ �r SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED H-S9 3M 3-'63 F.F.CD.