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FOR OFFICE USE: - ---------------- - ,��ti----- -- - --------------- APPLICA R FQ'RI SANITATION PERMIT Permit No. ___ ........_.... .... -- ----------------- -- --_--- " (Complete in' Date Issued Duplicate) _ 9 ILS This Permit Expires 1 Year From Date Issued _ _ 3 ------------------ ------------------------- 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. b ` JOBADDRESS AND CATION.-------------`----------------------- ------- /•------- ------------------------------------------------------------------ Owner's Name • --- ------------------------------------ Owner's Phone - j r: Address---------- •-------------------- ---------- ------- Contractor's Name __ __ --d-------------•- - --- - ----------•--------•---------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Comm&cial ❑ Trailer Court ❑ Motel ❑. Other ❑ Number of living units: ---- Number of bedrooms ___L---Number of baths _/..__ Lot size ___________________________________________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table-/__7 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gj-4H9'rdpan ❑ Previous Application Made: (If yes,date----------- --------) No' ewConstruction: Yes ❑ No A: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation_______________-__.Material--_._-__---------_.______._.________..__________- �- ❑ No. of compartments--------------------------Size------ ---------Liquid depth---------- ------------- Capacity--------- ------------- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________:_______ ❑ dumber of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ -Type of filter material--------_------------_---Depth of filter material---------------.--------Total length------------------------------------- ---- I Seepag it: Distance to nearest well___ �Distance from foundation_��___A�. ..___.Distance to nearest lot li?re__6___ ____ Number of pits.-_._1--------------Lining mateSize: viameter��3----------------DeptH.,2s:- `_ Cesspool: Distance from nearest well ______________Distance from foundation---- p ------- .Lining material-------------------------------------- El Size: Diameter--------------------------- --- -----Depth--------------------- ----------- -----------------Liquid Capacity - gals. Privy: Distance from nearest well---..-_____---------------------------------------Distance from nearest building____.__._______---------_--- ..___.._. [] Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-----.------------- -- ---------•---------------------------------------------------------- -------- ---- ------ - - - --.-- - ------------------------------------ --------- _ ------------ -- ----------------------- ----------------------------------------------•----------------------------•------------------------------------------------------------------------------------------------------------------------ I hereby certify that ave prepared his application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and les ander u +i s of the San Joaquin Local Health District. (Signed) } --- -- - ------ -- ---- ------- -------------------------------------------------- (Owner and/or Contractor) --------------------------- y� By- - - - �rtlel /-Z� (Plot plan, showing size of to , I cation of system in relation to wells, buildings, etc., can be placed on reverse side). _FQIDEPAYFMENT USE ONLY APPLICATION ACCEPTED --------------------- ._____ DATE__!.Z-___ ________________________ �. REVIEWEDBY - -- ----------------------------- DATE------------------------------------------------------------ # BUILDINGPERMIT ISSUED--------------------- ----------------------- --------------- --------------- DATE------------------------------------------------------------- Alterafions and/or recommendations:-----/`on—'------- ` ........... _______________________ ------------------------------------------------------------------ ------ ---•--•--------------------- • ---------- ---------•----- -- ---------- - -••------------- --------------• ---•-------------- ------------°- ---------------------- --------_------------------ l_ ' FINAL INSPECTION B ----------------- ---- ------- --- --- --- ------ - ---- -- 'r Datee---5 I` ---- SAN JOAQUI LOCA EALTH DISTRICT 1641 E.Maselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California rlS 9 REVISED 8-59 3M 3-'S3 F.P-Ca. r