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FOR OFFICE USE: - ---- --------------------------------------------- -------------------------- ----------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. . -(!� •x%_� ---------------------- --- ----------------------------- [Complete in Duplicate) - pate Issued ______ ---.__-_..____________________________.-...___.____.--_ This Permit Expires 1 Year From Date Issued IJ-. 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 o. 549. n c JOB ADDRESS AND LOCATION -- --------- -2"i ------- `" `=------ --- -----• Y-2 ------------------ ----------------- Owner's Name----- .-u ---- --- & --------•----------- --------- Phone------- ------ ----AAddress--------- ddress---------t Z^ - - ------f--- -- -- ---- - - -------- - -------- -------- Contractor's Name---------5- --------- ----- •- -- ----------•- -- - --- -••-•--•----- Phone-----_-----------• ------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1--- Number of bedrooms__ Number Baths __/_ Lot size ------ -_. ____ ----------------------- Wafer Supply: Public system E] Community system ElPrivate pth to Water Table � ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ElAdobe Hardpan ❑ Previous Application Made: (I€yes,date---------.-------...) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: �ank: o septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Distance from nearest well-----_._o___-Distance frorr- foundation_______ ________-Mat r I----- ---------------_______ No. of compartments---------.�._ � `S.___Liquid depth________ __________._ p y-- o -------'.-Size- __-� I -_-Ca aci# �O__,� Dispos ieid: Distance from nearest well....`5'.Ot.------Distance from foundation___._�_0___.....Distance to nearest lot line__`_ __._.___ j Number of lines_____________y____-_______�___- Length of each line-_470.1------------------ of trench__._'Z.-._,__.____.___._._______ Type of filter material_./L Tl _ Depth of filter material__1.�______________Total length_-!4 ------------------------------- See -.-._____________._-_ � r Ft Seepa Pit: Distance to nearest well------ f1a._:__Distance from f ndation_____f_�.._____.Distancet o nearest lot lin�e+__5-------- (� Number of pits....___,_.__________Lining material__/ _-Size: Diameter__._____ ..___.Depth_-_-.v __________..___ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---.----------------._-_-_____-______ b• ❑ 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)------ --------- --------'------------------------•--- --------------------------------------- -•---------------------•----------------------------•--- -•--•-------------------------------------------------------------------------------------- --------------------------------=----------------------------------------------------------------------------------- . •. --------------•----------------------------•-------- ---------------------------------------- ------------------------------------------------------------ �+ ------------------------------------ ------------------------------------------------------ --•------------------------- ---- ---------- "} -------------------- -------------------------------------------------------- I hereby certify that i have pr pared this application and that the work will be done in accordance with San Joaquin County ordinances, $ta WS, and rules d regulation of the San Jo quin Local Health District. a• �, .� (Signed)-=----- --- --- ----- ---- -- ----- ----------------- ---------------�,d/or Contractor) By:----- -_�------ ---E ----- ---------------[Title) (Plot plan, showing size of lot, location of system relation t wells, uildings, etc., can-6e-placed on reverse side). T ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ,,,,e - -------- DATE---- F ------ ---- --------- - REVIEWED BY-------------------------------------------- _----------------------------- ------ -----.- ----------------------------- DATE-------------------------------- - ------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------- ----------------------------•----------------------------•-------------------•----------------------------------------- ------------------------- -•------------------------- ---•-------------------------------------------------- -------------•-----------------------••------------------•------------------------------------------------------ --------------------------------•-------------------------------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------- -----•----------------------------------------------------------------------------------------------------------------------------------------------------------------1l------------------------------------------------------ -lD� FINAL INSPECTION BY:_- 4._ ------------------ Date.-------.f _ _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-•63 F.P.1013. -