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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITPermit No. ---------------------------- ---------------------------- ------------------------- --- (Complete in Duplicate) $r This Permit Expires 1 Year From Date Issued Date Issued ---- _/._TA y 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. JOB ADDRESS A LOCATIIONOO ,�� om Owner's Name_------- �l _ az --------•------ -------------- -- P one---------•------........... Address !, L + -- r Contractor's Name--- ---- + ` --------------------- -------- - Phone............................. . Installation will serve: Residence 2! Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J--. Number of bedrooms __ht'. Number of baths ---?`r of size ....... ------------- Water Supply: Public system ❑ Community system ❑ Private �pth t Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 7lay Loam ❑ Clay ❑ Adobe❑ 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 nk: Distance from nearest well-------54_ F _ _Distance from foundon.------ ---Mat i L_-_. �_-- ------ Li uid de th__..__a _________Capacity--.'-a-�E'No. of compartments....A-__ ..-__.._- Siz Dispos ield: . Distance from nearest well.... Q�__Distance from foundation...�_Q_..._._._.Distance to nearest lot line-.-.-/ Number of lines-----_______________________Length of each line-------- ________..Width of trench._-_--2-�______-------_____.. Type of filter material___. .�-_--__-Depth of filter material.------ length__,��0-.---_________________ �� Seepage Pit: Distance to nearest well------_________-------Distance from foundation....................Distance-to nearest lot line-------.------... ❑ Number of pits-_-------------------Lining material_-__.___mm_---____.Size: Diameter---------__--- ---____Depth____-------------_.......--______ Cesspool: Distance from nearest well-----------------Distance from foundation___----_._-------_.Lining material-------------____---------r_--__-_-. ❑ Size: Diameter-- Depth ------------• ------ Liquid Capacity------- -------------gals. Privy: Distance from nearest well---_______-------_mm---------_------______-----Distance from nearest building_-___-----._-.-__._-__. ❑ Distance to nearest lot line------------------------------- -----•-----•----•----------------------------- ------ •------------------------ -- Remodeling and/or repairing (describe):-- ------------- ----•- •-------------•--------•---•- ---------•----------••------------------- --•---•---•---------------------•------------•--•------------•---------------------------------------.......................-----------------------------------------------------------------------M------------------- -----------------------•--------•- ------••-•--•-••--------•----------------------------------=-------......----------......................---.....------------•-------------•--------------•------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws a d rules and regulations of the San Joaquin Local Health District. (Signed)---- - ------ --------------------------------- --.- �---- W�farnd/or Contractor) . -- �-- -�-- -- - ------------(role)- ----------------------------- ----- -- ---- -------- (Plot plan, showin sze of lot, location of syste in relatiil, to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____,. .____ .___ _, �..-:� '1rt }__ _________________________________ DATE _ .. REVIEWEDBY--- ... ------------------`--- ------- ---------------------------------------- DATE------........... ---------------------------------- BUILDINGPERMIT ISSUED---------------------------------- -------- ------------•--•-----------------------•-•-•----------- DATE................------------------------------.........------ Alterationsand/or recommendations:--------------------------------------------------------------------.......................-.....................................................-------------- -•------•--•------------------------------------•.....__...--•--------------------------------------------- -------------. ---------•-----•---.........................---.....-.........-......................._....... ---------------------------------------------------------------------------- ---------------------------•-.....................----..................................... .................--------------.....----------------- --------------------------------- ------ -------------------------------------------------------------------------------------------------------------......--------------------------------- ---------•--•-------- -------------- --------------................... ------------------------------------------------------------------------------------------------- L FINAL INSPECTION BY:. /i '"2' i? ---------------- 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.