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FOR OFFICE USE: �� A + Nrmit P f 1 .. s _----------- APPLICATION FOR ;SANITATION PERMIT e q� -------------------------:------------- (Complete in Duplicate) -------------- -- This Permit Expires I Year From Date Issued Date Issued .v�_.� ___-------1 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. r , JOB ADDRESS AND L C TION----------- - ---1,----- -------- -------------------------_.-........ Owner's Name ------ Phone.. Address----------------------------- • -------- ---- -------------- -------- ------- ------------------------------------------------•-•----------------------------------•- Confractor's Name-------- -- --- ---- - ----.------ ----- ............. - Phone__=r..-._&/__.... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms __cW_ Number of baths __/__ Lot size __,7_ __' __/. ------------------ Wafer f______________Water Supply: Public system �ommunity system-E] Private ❑ Depth to Water Table 3_�4ft. 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 ❑ New Construction: Yes ❑ No [4--1_HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet,) `• pti ank: Distance from nearest well__________ _____Distance from foundation--------------------Material_--____--____---_____----_________--__________- No. of compartments-- ---------`t----Size----------------------------_.Liquid depth-------- ------Capacity----------------------- Ms osal ed: Distance from nearest well Distance from foundation_,�Q-______Distance to nearest lot line__P_____ P � ) Number of lines___.- -�____ ength of each line------------s3_Q__ -.Width of french_'-__-_c .f�-- -�__ / Type of filter material__ C Depth-of filter material___B___----Total length_________________--------20____-_ t , Seepage Distance to nearest eI Q1CQ�Distance f m fo dafion__-/Q--------Distance to nearest sot line_�_CJ____-- [ Number-of pits______ ___________Lining material Size: Diam'eter__._ - __-...___uDepth'__.___ .S_____._____-._'r Cesspool: Distance from nearest well-----------------Distance from foundation_...___.-"_"_ -Lining material-__.____-__-___-___________-____--__-- ❑ Size: Diameter-•---:- - ........Depth-N------------------------------------------------Liquid Capacity---------------------------gals. Py: Distance from nearest well________________ _______`__--\____._-_ _._._;Distance from nearest building----------------------------------------- Distance E ceto nearest lot Ione--------------------------+ - -�,4 -� m ------------------------------------------------------------ -------------------------------- Remodeling and/or repairing {desc"ribe)_------____---------------------------------------------- --------------------_--------________________________________'___�____________________-___--____________'_--_-__-___________�__-_ '� Fi 0 ------------------------------------------------------1-------------------------------------------------------x-------------------------------• --------------------------•---------------------------------------- 3 t - -- - -------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and rules and r gulations of the San Joaquin Local Health District. (Signed)------- -------------- ------------ -- /---- --------------------- -- ----: ---- --------- --------- T::r--------- --------------------------- ------(Owner and/or Contractor) h By----------------------------------- ` - - -----(Title)-- ------- - (Plot plan, showing size of,lot, location of system in Tela wells, buildings, etc.,can be placed on reverse side). r.. FOR DEPARTMENT USE ONLYr / APPLICATION ACCEPTED BY------------ ------------ -=—_ _------------------ ----I---------- DATE------ '� f� REVIEWEDBY--------------------------------------------- - - -------------------------------------------- ,------------------`---------- DATE------------------------------------------ ---------------- BUILDING PERMIT ISSUED-------- ------- - -- / DA•TE------------------------------ ----- ---- ------------- Alterations and/or recommendations:-_________Z �l��.___ - /QCs_____ --------------------------- ---- ---------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------- ------------------------------ ------------ - --------- ------ -------- --- --------------------------------------------------------- -------- - ----------- ------------------------------------------------------------- ---------------- --------------------------------------------------------------- - ------ ------------------------------------------------------- - ---- ------------------------------------------------------------------- FINAL INSPECTION BY--------------- ----------------------------- Date - --------------514A- ---------------------------------------- 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.P.C C. l