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FOR OFFICE USE: -------- ----- - ------------------- - ----- -- - ------ -- ----- --- ------ ----_-------- - ------------------ APPLICATION FOR SANITATION PERMIT Permit No. ... ..`�...�,1`/ � �. -- --- -- - -------- (Complete in Duplicate) / ! �-------------- .._________.._..._._________.__. This Permit Exaires 1 Year From Date Issued 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. JOB ADDRESS AND L 101 - _ '21?---+--•'------fie' OwnersName------ -•------- ............ ----- ------ -••-------- --- ------------------- -- -------------------------------------- Phone.................................... Address............-�- ... �/-�-- ----------- - -- --------- ' Contractor's Name.------... -- ----------------------- ......... Phone,.................................. Installation will serve: Residence (G Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._.. Number of bedrooms __/__ Number o baths �/_--- Lot size ...... ---------------------------------------------- Water Supply: Public system El Community system ❑ Private Depth to Water Table ...... ft. Character of soil to a depth of:,3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam Clay ❑ Adobe❑ Hardpan ❑ Previdus,Application Made: {If yes;date.______ ___ _______) No ❑ New Construction: Yes ❑ .No- ❑ FHA/VA: Yes ❑ No ❑ INSTALLATION TYPE OF INSTALLATION AWSPECIFICATIONS: (No septic tank or cesspool per-miffed 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------................ Dispos Field: Distance from nearest well -,5d--l._Distance from foundation -14 j ...Distance to nearest lot line...... ...... Number of lines ._..-._.- -,..._. -}..___Length of each line___._..�Q................Width of trench n Type of filter mateal..`--._a$" ___ _Depth of filter material-------I-V:.......Total length........4.!g....................... y= Seepage Pit: Distance to nearest well.-.-------- __...-Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining materiat_:. ------ ----Size: Diameter------------------------Depth---.------•-------.------_------- Cesspool: Distance from nearest well-----------------Distance from foun*tion--------------------Lining material----------------- .................... ❑ Size: Diameter--------------------------------------Depth------------------------------ ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----___=----- -------•-_---__- __--_-_[Yistance from nearest building-_----._---.---________--------------__. ❑ Distance to nearest lot Ifne-:_= --- ----------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--- > ---------------- -----------------. --------------•--•-----------•--------------------------------------- --------. ------------------- ------- --------------------.---.------------------- -- -------- - I herebycertify that ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, rid rules and regialatio the San Joaquin Local Health District. (Signed)------------------- -------------------------9-_-- By: - ---- - --- -- - --- --- - --------- ----- - ..-_--.� and/or Contractor) --------- - --------------- •- •----- -- ---- (Title)------------------------------------------------ ------------ (Plot plan,showing size of lot, location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACC EQY _ ------- ------ ------_______________----------------- DATE---- REVIEWED BY........... ... --•--�� ---••• DATE...........................................-•-••-•--•------ BUILDINGPERMIT ISSUED--------------------------------------------------------------—...................................... DATE-----------------------------------------------.............. Alterations and/or recommendations:_---------------------------- ------------------•-----•---•-•--•--••-•-••-----•--------•------•------•••---------------•-••--------••......----•-••-•--------- -----------------------------•--------....--------•---------------------------------......----------------------------------------------------------•-----------•-----------------------------------•------................ --------•-------------------------------------------------------------............................................ ••---------• ---------------------------------------•--._.._..----•-------------. .........•--- 9 l J 9 FINAL INSPECTION BY: Date ------� -- (s'S� /��'�'" SAN JOAQ UIN 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 E5 9 REVISED 8-59 3M 3-'63 F.P.CC. `