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FOR OFFICE USE: t, ---------------------------- --- --- -------------------- APPLICATION FOR SANITATION PERMIT Permit No. .....:........ __________ _ _ (Complete in Duplicate) o -----1 _ -------- -------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDOCATION•-J0)®''-''4,- ---- /� . `'s�` ------ ............ Owner's Name---- � ,+"*' _ �'--- =�•-��-= �"�,�"--------------------------------------- - ------ Phone..........................__------ Address..................Y`---- 3 -� ------.-p-7-- ---•--- — ----------------------- --•--•-------------------------------------------•--•--------•-----------•-------•---- Contractor's Name...,*,.t------------------------------------------------------•--. --------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence 1�j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I Number of living units: .�----- Number of bedrooms _,.3----- Number of baths __/_... Lot size -1'' _l' _..-__--•_-•----------------------- Water Supply: Public system ❑ Community system ❑ Private Ej] Depth to Water Table�r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ Clay ❑ Adobe,E] Hardpan ❑ Previous Application Made: (If 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_-___--__--__-----.---_-_--__--___--_-_-----____. ❑ No. of compartments--------------------------Size---_---------- --------------Liquid depth------------------------._Capacity-•-------------------- Disposal Field: Distance from nea�st well_t_0-_-__.._Distance from foundation...a'L.a'_._-•--_-Distance to nearest lot line---k"�.._.... �] yp Le11 P th of each line-----�_c��f.---_--_-_-Width ofgtrench__}:.Y__'";__.__.._._____...._ Number of lines___ _ h of material Seepage Pit: Distance toenear nearest well _______________D Distance frotmrfoundation...._...____--••__Distancentohn�r� lot _ line---------------•- ❑ Number of pits----_----------------Lining material-----------------------Size: Diameter_----------------.---Depth_.------------------------------Ile Cesspool: Distance from nearest well-----------------Distance from foundation---------------.----Lining material-------------------------------------- El 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 County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (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...b�_2 --4 S --------------------------------- REVIEWEDBY----------------------------------------------------------------- ------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED...................---------------------------------------------------------------------•---------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------- ----------- -----------------------------------------------------------------------------------------------•----•-------- -_--------------------- ----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------- ----------------------------------------------- ----------------------------------------------------------------------------------------•------ ---------------------------------------------------------------- --------------------------------------------------------------------- -------------------------------------•---•--------------------------------------------• ---------- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ f .r-7 -aS` FINAL INSPECTION BY:.--f 8.1-14 ; ------------------------- 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.