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FOR OFF1,CE U E: t 2 $. -----114W, --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------ -------------- (Complete in Duplicate) (o r _____________________.__._________-._._._._________._._ 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 NOF, 549. JOB ADDRESS AND CATION---- `- e------- --------------------------------------------------------------------------------------- Owner's Name------- ----- I ---=------- -- --- Phone--------•-•-----------------•---•--- Address--------------- - "------- Contractors Name---------------------------- Installation Y Phone................................... 1�,�- "------ - - - ----- ---••--- ----- - --------- --------•- - --------•..------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othpr ❑ L Number of living units: __/__ Number of bedrooms Number of baths _!___ Lot size . t -----------------_______________ Water Supply: Public system [, "Community system ❑ Private ❑ Depth to Water Table4�?tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---------------------) No ga",- New Construction: Yes ❑ No ®—'FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: j (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__- .__Distance f om founclation./P_______.Mat;ial____ _�f ._- ®� No. of compartments____:, _____ Size_ls __.___Liquid depth____ __-.___..____Capacity____ __ Disposal Field: Distance from neares} well---- ---Distance from faundatio _ 010_!_ Distance to nearest l t line__.......... Number of lines_______________ _ _ Length of each line______ Width of trench____/� __________________..._ r Type of filter mat erial��/�- _.__Depth of filter material _Total length__ \ Seepage Pit: Distance to nearest well---_._"---------Distance f m fo dation---x1f(___.Distance to nearest lot line__+a0. /- Number of its_____ __..___________Linin material ,Q_e� Size: Diameter_ P r 9 ,. ��------ Depth----v ` 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]:----------I. ______ � __ wvl�4- r ---- - ---- - ---- ------ - •----- -- ----------------------------------------------------------•--•-------------------------------•----------•-------------------------------------------------------------•-------------•--•-----------•--------------------- I 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 rulps and re ulations of the San Joaquin Local Health District. (Signed} ---- ----------� ------- - �er Contractor) B '� -- --_(Title)----tom ` -.----- (Plot plan, showing size of lot, location of system ' elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----C------- - ------------------------------------------------------------- DATE-- Z L--------- ----------------- REVIEWEDBY----------------------------------------------------------------------------------------•------------------------------------- DATE--------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------•-------- Alterationsand/or recommendations:-------------------------------------------------- --------------------------------------------- ------------•-------------------•------•----------•----------- ------------------•----- -------------------------•-•-------•---------------- --------------------------------------------- ---------------------------------••--- ---------..•-------------------•---------------------- --------------------------------------------- .--•-•-------------------------------------------------------------•---- - ---------------------------------- ----------------------------------------- ----•------------------------------------------- ------•-------------- - --------------------------------------- - ------------------•-------- .......... ----------------------- ----••--------- FINALINSPECTION BY:.-C..-----1� -. ----------------------------------- Date--- l ' I----•- ------- ---------------------------------•--•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 41h Street Stockton,California Lodi,California Manteca,California Tracy,California Ea-9 REVIPFO 8.59 r.P-rD.7M 6-60