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F R OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..., ..�-- -d ----------- ------------- ------ ------ (Complete} in Duplicate) Date Issued / This Permit Expires 1 Year From Date Issued # 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 Vo. 549. JOB ADDRESS AND LQCATION__ _____ � -----------------------------------------------------------------------------. ------------------.-------------- I'b_ _ •-. Owner's Name--- ------ ----�f=� ` ------------------------------------------ ---------------- ---------- ---------------------- Phone------------------------------------ Address--------- -•-••---------•--------------•----- Address--------- :r3 -- -- S Contractor's Name ---T•-•-------------------------------------------- --•----------•-------------------.._- Phone. - i Installation will'serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _r-____ Number of bedrooms ____Z Number of baths __Y�___ Lot size _ -- _ 3J-------------------------------- Water Supply: Publictsystem Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: llf yes,date--------------------f No New Construction: Yes Pj—'N—o ❑ FHA/VA: Yes ❑ No [�J — TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' r Septic nk: Distance from nearest well---_'---------Distance from foundation_- -------------Material---�/�_ ______-.-----_____. No. of compartments__kn------------------Size_t3xXc7y..9---------Liquid depth---_!Y_------ ------._Capacity.... 00 Disposal Field: Distance from nearest well_. _ _-_-Distance from foundation_��-------------Distance to nearest lot line----._._.______ RT_ Number of lines------/------------------------------ of each line___5?41-------------------Width of trench_�4--`--.--------------.--- ., Type of filter material�DL k_______Depth of filter.material-___I�'_________-__Total length_.__ Q__ ______________.__________ f �i Seepage Pit; Distance to nearest well-�.-'_____._____Distanr from undation__ Q.......:.....Distance to nearest li�� ___________ [ Number of pits------- -------------Lining material_____0 -- ------Size- biameter._. 3-- Depth-------J-------•----------_---- Cesspool: Distance from nearest weld__________ ____Distance from foundation--------------------Lining material____._._.___-___--.----________---- ❑ Size: Diameter-----------IF--------------------------Depth--------------------------------------------`--------Liquid Capacity---------------------------gals. Privy: Distance from nearest well----------------=----------------------------- Distance from. nearest b0cling------------------------------------------ on ❑ Distance to nearest lot line---------- --------------------------------------------------------------------------------------------------- ----------------- '� r Remodelingand/or repairing (describe)-------------------- ----------------------------------••--------------------••--------------------------------•---------------------------------•-------- ----------- -----------------------------------------------•:--------------------------•--------•------------------- t -- --------------------- ------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State [aws, and les and regulations of the San Joaquin Local Health District. (Signed) S)�� . ( for Contractor] ------ .. ... .........:,/--------------------------------------------------------------(Title)------ . ------•---------------------- ---- --------- BY= (Plot plan, showing Size of lot, location of system in relation to wells,r buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY- -;e--- -------------- ------------------------ ---------------------------------------- DATE------ — ---��---- ------------------------------- REVIEWEDBY----------------- - DATE----- -- ---------------------------------- BUILDING PERMIT ISSUED-------------------_-.----------------------- ----------------- DATE ------------------------------------------ � Alterations and/or recommendations: - : 4Y ----- - ------ " ---------------------------------- - ------------ --------------- ------------------ •---- - -------_---___---------------------------____------_-----------------------_------------_____________________________________________________________________________________________________ _____________________________________ ......... ..-_�-------------------------- ---------------_______._____.__-_______- _______._____.___.-_____.___.______-_-.__________________----_______-._.-__-.____._________.___-______ k Date--------- ----------------------------------- FINAL INSPECTION BY:----------------------- ---------------•---------- ---- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVISED 43-59 3M 3-'63 F.P.CD.