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FOR OFFICE USE: -------------------------- --------------- ---- --------- ---------------------------- - - - APPLICATION FOR SANITATION PERMIT Permit No. . �o ------ ------- -------- it ----------- (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 construct and install the work herein d cn d. This application is made in compliance with County Ordinance No. 549. f JOB ADDRESS AND LOCATION...�L' _._i_ __-_-___-"--"�"__.. _ /1t1.VZ_,.1X__Z.-;41.�/0 ----------------------------- -- Phone------------------------------------ Owner's Name--------- --------------------------------------- -------------------------•-----------------"--------------- Address------------- -�--------y-----e....... .r -r+ ................. ----------------------------------------------------------------------------------------------------------- Contractor's Name__4. , _» »�-------------------------------------------------------"-..."--...------------------....---------------"------------ Phone----------------------------------- Installation will serve: Residence (�? Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - ----- Number of bedrooms - Number of baths -1----- Lot size ----- --------------------------------- Water Supply: Public system ❑ Community system ❑ Private JE] Depth to Water Table . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam C`] Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date---_____-------_____) No [F New Construction: Yes 2' 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___��_.P------Distance from foundation__._x__0---------Material_.A �.». 4'`t__._____"_-----------.---------- r, No. of compartments------ "^----------------Size__y.'L_��'__s$�______Liquid depth______�l______________.Capacity_,/a'Z_-__ Disposal Field: Distance from nearest well__4'_0--------Distance from foundation./d------------Distance to nearesfjot line... .;._.__. Number of lines_...__-_____ _____ ______ ---Length of each line-----4J_.Q-----------------Width of trench __f__c - _'_-._-_ Type of filter materia .__Depth of filter material_____l. °_______Total length----16_D_"________________________ Seepage Pit: Distance to nearest ,I----------------------Distance from foundation"-________----__-.Distance to nearest lot line----------------- 0 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 well-------------------------------------------------Distance from nearest building"__.-____"_".__.-_-_______-__--.-.--..�,�► ❑ Distance to nearest lot line---------- -------------------------------------------------------------------------------•------------"------- ----"---- ------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------- ------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Cou ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------C -----4=------)&Is"V-:i ----------- ----------------------------------------------------------- ---------------(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_.,�'7,Z.Y_-0/_�-------_--- ----------------- REVIEWEDBY------------------------------------------- ------------------------------------------------------"•------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations-------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------•----i-------------------------------- .•---------------------.._."....._----------------- -•---•--------•--_-"---.......................------•--•--•----------------------------------- -----•---- ----------------•-------------------------------------•----------------•...---•-•-------------•----------------------------------------•------•---•-----------------------•-------------•------------------ ------ FINAL INSPECTION BY:._,;; _ � ------------- ----------- 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. '1 - -"--.•