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F R O FICE USE: 00,0 i _--_-- APPLICATION FOR SANITATION PERMIT Permit No. .--./........... ...: =- - --------------- --- - - -- -- ---- ------------------------- -------------------------- (Complete in Duplicate) ------------------F --------- ------------__ - This Permit Expires 1 Year From Date_Issued 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 No. 549. S. - CLDo�— o• s-��# f : JOB ADDRESS AND LOCATION_______ _ _____...�________.__._ ___________ #�._._ .. -------------- ---------------------- Owner's Name - �- ""� ---•• ------------ Phone --------------- ---- --------- -------------------------------------------------------------------------------•-------------------....__.. S Contractor's Name----- ---- - -------•--...-------------•-------•----------------------------------- - -- --- �honc....-----....------------ - ------------------------------------------- ---------- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court to OtherAA❑ Number of living units: _1_ Number of bedrooms ___2 Number of baths __r____ Lot size ---------------------- Water ________`j_____Water Supply: Public.-system ❑ Community sysTe —[I Private Depth to Water Table _. t. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam y E] Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-------------- --) No New Construction: Yes ;:Wo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.] �--� Septic k: Distance from nearest welL-57-9--------Distance from foundation-Zd_-.�----------Mat riaL__-1 _ _________ No. of compartments____--2.___------_._-Size___3,X._5-X_q_-.___Liquid depth___`...............Capacity---- ------ ----r Disposa id eld: Distance from nearest well-i!0 from foundation___� _r________Distance to nearest lot line_'"_-------------- � Number of lines---------Z----_______._________Length of each line___-j"0---------------------Width of trench.._9_15__''__.._______.____ Type of filter material et_[_- _____Depth of filter material---/. __�`_-____-_Total length___-__g-._r/----!--------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter.-----------------.----Dept h----------------- - ---------____-- Cesspool: Distance from nearest well----------------Distance from foundation---------------------Lining material----------------------- ❑ Size: Diameter-------------------------------------Depth------ ---------------------------------------------Liquid Capacity-.--------------------------gals! Privy: Distance from nearest wO---------------------------.---------------------Distance from nearest building___________________.__________.._____-_._. ❑ Distance to nearest lot line--------- --------------------------------------------------------------------------------------------- -------- --------------------------- Remodeling and/or repairing (describe):------------------------ ---------------------------------------------------------------------------------------------•-------------------------. ; --------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------- -- -- ------------------------------- ---------------------------------•-----------------------------------•----•--------------------•---•-------------------------------------------•---------- ----------------------------- I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regu'a'io s of the an Joaquin Local Health District. I (Signed)-------------------------------------------- ------- - - --- -- --- - ---- -----------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------- --- - -- ----------------- ---------------------------- -----(Title)-- ------- -------- ----------- -- - -- --- -------- , (Plot plan, showing size.of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- ---------------------------------------- !tib`5--------------- DATE---------- 4-3--------- REVIEWED BY. DATE ---- -----------------------------•------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- -- Alterationsand/or recommendations------------------- ----------------------------------------------------------------•--------------------------------------------------------------------------- ----------------------- ------------------------------------------------------- ------------------------------------------------------------•--------------------------------•------------------------------------------ ----------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------•--------------------------------------- ----------•----•---------•------------------------------------------•-------•------------------------------- ---------------- ------•- ------- -•-------------------------------------------------------- --------------------- ! / �. -` -- FINAL INSPECTION BY--- ---------- - ----f.��-------------------- --- Date------------ -------------------- ------ / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca;California Tracy,California EV 9 REVISED B-59 3M 3-163 F.P.CD. d