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rUK UWCE USE: — -- ----F r -------------------------------------------------- ------ ----------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. / ._ •___,�� ------- ---------- ------------ ---- --- ------ {Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ------ C.63 Application is hereby made to the San Joaquin Local Health District for a permit to`c,o_nstruct and install t4e work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L" CATION - i Ec -- ---- � ---- Owner's Name '��'�-----"--------- ---------------- Address # '�.jI -- ---.. ------ Phone- •--------------- Address----------- ------Confractor's Name"--_-__"__. ,4�� - -----. Phone---•--.........:--------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: (�--___ Number of bedrooms _-, Number baths j-_- Lot size "-_-_ " __._ ._ -•- 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' Clay4 ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ ' No ❑ FHA/VA: Yes E❑ No ❑ TYPE.OF INSTALLATION AND SPECIFICATIONS: (No sep+ic tank o r cesspool,peritted:if_public s�r is�availableawifhin 200 fee},) ....r Septic Tank: Distance from nearest well -----_--" 'Distance from foundation """ Material_"" a . :., ; _ - --- ----- - No. of compartments Size- -------- -�' =--_ -Li_quid depth ----- ---------------_ , Capacity ------------------- Dispo Field: Distance from nearest weil ......Distance from fcundation��-;,!.Distance to.,nearest lot line"- _�_____, E/ Number of lines--------I-------- ------ --_ " Length of each line_--1 b_�."- ___-"_Width of trench-. -4 -" _Type of filter ma#erial" _ -Depth of�.filter material------,lf'-_ _-----Total length.----_s-_ _-""---_ p ---- ... _4 s # See e Pi#: urRbeeof ntarest well:----Linin maDteraal a=from foundation_- --•-".Distance to nearest lot line----------------- 9 __ g ..Size. Dsameter Depth Cess 1 --- pool: Distance from nearest well---_------_-_--_Distance from foundation----------- -- � - -----.Lining material----------------------- EJ ------------- Size: Diameter-----:------------------------.-------Depth-----------------.---------.- ------Liquid Capacity-------------------- -------gals. Privy: Distance-from nearest well--_--__.______-_-------._ - --------_Distance from nearest buildin 9 = ------ ❑ Distance to nearest lot line ........- -a ,, ------ Remg�a' an or repairing (describe):_-------- ------------------------------------------------------------------- OQ --------------------------------------------- -------------- -------------•----„ --------------------------- ---•--:-------•---------------------------------------------------------- -----------•---------•------------------------------------ --- 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 regulafiorw of the San Joaquin Local Health District. Ay _ r Contractor) ) (Plot plan, showing size of.lot, location of system in relation wells, buildings, etc., can rbel placed ed on reverseV side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- REVIEWED BY------------------------------------------ -- --------- ---------- ---------- ---•---------- ---------- ----------- •--- DATE ---------------------•--�--------------------------------- Alterations ------ - . BUILDING PERMIT ISSUED------------------------------------------------------------ -------------------------- A terations and/or recommendations-------_----- ---- ._.."- -------------------------------- --------------- --- ----••----- -------------------- -------- - •FINAL INSPECTION ----------------- -Datet� • SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E,Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th S►reef Stockton,California Lodi,California Manteca,Californiai Tracy,California ES 0 REVISED M-59 3M 3-'63 F.p,CD.