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— FOR OFFICE USE.- ---- -- ----- - -- APPLICATION -F6R SANITATION PERMIT Permit No. _. ......._ ------------------------------------------------------- (Complete in Duplicate) Date Issueds j tf'w -_..----------------------------------------------------- I 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 No. 549. L/fJ/JI�C, JOB ADDRESS AND �LOCATION---------_-------- --- �----------71'--t----------__ 3 w,. "� � ?J Owner's Name......!/,�!!-�-------W_�------ � ----- Phone..........................--------- Address --•----- Address.---------•----Q:�!'T..__/-------1 --------------------------------- ----------------------....--•--•---------------•--•--•-••--_..... Contractor's Name ........... ----------- Phone................................... Installation will serve: Residence IV Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1.... Number of bedrooms _./--... Number of baths Y----- Lot size ----- ►-------------------------------- Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table A4 ft. 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 IJj New Construction: Yes, n 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__�7q.-----Distance from f`o`undation---Z-0 -----.Material--- --_----------------- 03 No. of compartments.-_.o-7_---------------Size._.-.... 3 .�-_d"_..-.._ S .-------Liquid depth--.A/---------------_--Capacity__(hOQ--------.-- Disposal Field: Distance from nearest well---6'O-------Distance from foundation..-/6---------Distance to nearest lot line.$._............ 00 Number of lines_._ -----_ Length of each line...... P e_-..----._.Width of trench.._-c7-Y---.-_-.-.--.-__----. Type of filter mate ria% �1 ..Depth of filter mate rial . Total length , !Q r Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits.---------------------Lining material-_----_--_--- p -------Size: Diameter----•-•----------------Depth Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material_-..-_._..._--------.----.-..--._.-.- d ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------•------------•--gals. Privy: Distance from nearest well---------------- ----------------------------Distance from nearest building_..---.._-._.-.-.--_-.-------.---.------- ❑ Distance to nearest lot line---------------------- ------------------------------•---------------------------------------------------------------------------- ---------- Remodelingand/or repairing (describe):-------------------------------------------•---------------------------------------------------------------------------------------------------------- ---------------------------•--------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------.. --------------------------------------------------------•------------------------------•------•---------------------------------------------------------------------------- ------------------------------------------------- - ------------------ ------ p I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ea.— (Signed) -------------------------------------------------------------(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 APPLICATION ACCEPTED BY-------- - - ------------------------------------------------------ DATE..._eS� REVIEWEDBY................--------------------------------------------------------------- --------------------------------------------- DATE----------------------•--------------------------------•--- BUILDINGPERMIT ISSUED------------------------------------------------ --------------_------------------------------------.- DATE............................. ------------------------------ Alterations and/or recommendations:............................................................................................................................................................... ---------------------------------------- ------------------------------ ------------......---------------------------.-.-----•-------------------------------•----------------------------------------------------------- -------------------------------------------------------•---------...---------------------------------------------------------------------------------------------------------------------------------- -------------- -----•-•------- ------------- --------------------------------------------- --------------------------------------------------------------------------------------------------------------- ---------------------- ------ ----------- ------ --------- ---------------------------. - ---------------------------------------------------------------------------------------------------------------------------------------............ FINAL INSPECTION BY4 --------- ------------ 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 ES 9 REVISED B-59 3M 3-'63 F.P.CD. _