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FOR OFFICE USE: ----------- ----------------- --------------------- ------------- -- - ------------------------------------- f APPLICATION FOR SANITATION PERMIT Permit.No. :j2"eI .. ----------- ------------------------------------------ (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 constectand install the work herein described. This application is made.in compliance.with County Ordinance No. 549. �}Q�J_ Dp5' ;.2 S,3q I N• 6--,j c c4—= 4-xj " fJOB ADDRESS AND LOCATION Owner's Name-------_��__w.. ... --------- --- --------------_----------- Phone Address............W------Y..__..�.�.'-t.y----- -------••------- ----- --------------••--------------------------------------------....._----- -----•----------------•- Contractor's Name.- :' a .t --------------------------------------------------------------------------------------- ------ Phone-----------------••----•-•------.. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- 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 ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Iif.yes,date-..__.__ ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) ? Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material __________________________._-_-_._..-__---.. A ❑ No. of compartments-------------------- -----Size----------------------------•---Liquid depth---- ---------------------Capacity---------- ----------- Disposal Field: Distance from nearest well---4f''_._._Distance from foundation-_rx1_---------Distance to nearest lot line_;_L__0......... ') Number of lines-----*4----- ----------------Length of each line-----Y-u------------------Width of trench-_�'-�-------------------------- Type of filter material _f__------_---_Depth of filter material----/4.`-!-------.._Total length___a-___'__:.-_____________________ Seepage Pit: Distance to nearest well----]iQ-------------Distance from foundation--- A-----------Distance to nearest lot line_r--------.._ 1 kNumber of pits-.-1------------------Lining material_ '- :---------Size: Diameter---3 ............Depfh-.A-+'r7--------------------- Cesspool: Distance from nearest well-------------_.-Distance from foundation------------------ Lining material_--------- -----_-._--,._----__._-_. I ❑ T _ ,Size:-Diameter------------ ---------- --------- Depth-----------------------------------7---------------.Liquid Capacity------------------------- -gals. Privy: Distance from nearest well------------------- --------_----_----------------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line----------------- --------------------- ------- ----------------- --------------•---------------------------------------------------- Remodeling ---------Remodeling and/or repairing (describe) ------------------------------------------------------ ------------------------- -------------- ------------------------------------------ ---------------- ---------- ----------------------------- ' I ------ ------------------- --------------------------------------------------------------•------------------------------------- -- M b „I. 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 rules and regulati ns of +he San Joaquin Local Health District. Sined)---C ~ -- ------------------------ ------------------------------------------------------- -------------- ----------- By: ---------(Owner and/or Contractor) By-----—------- ---------- Title - -------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPL CATION ACCEPTED BY--------- . ....-�----------------- ------ -------------------------"-------------- DATE---Y-71-44---- REVIEWEDBY---- _------------------- ------------------- ------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- -------------- DATE.- -------------------------------------------------------- Alterations and/or recommendations:------ ------------------- ---------------- --------•------------------------------------------------------------•---•---•--------------------------- ----------------------------------------------------------------------------------------------------------------------••------------------------------ ------------------ FINAL INSPECTION BY:. 7 --------------- Date... ._-- 1 -- ---------------------- - ------------.--------- 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 "F L' t