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FOR OFFICE USE: i( APPLICATION FOR SANITATION PERMIT Permit No, ----- ----------------- ............. I� (Complete in Duplicate) • Date Issued _7/ . ......................................... ......... ..... This Permit Expires 1 Year From Date Issued i Application is hereby made to' the San Joaquin Local Health District for a permit t construct and install the work herein described. This application is made in compliance with County Ordinance No. 549, 7 Q 7Q ?�,J 0.51— 100-1QZ3 JOB ADDRESS AND LOCAT[ON.6t' Owner's Name-- - -------------- --------------- ------------------------------------------ Phone-------------------------------& V__ r Address ------------ - Contractor's Name _ Phone------------•---•-•----- I Installation will serve: Residenk a Apartment House ❑ Commercial ❑ Trailer.Court ❑ Motel ❑ Other ❑ 11 , � Number of living units-, ._... Number of bedrooms .. ._ Number f baths ._�__ 'Lot size -_-.-✓Q_.X. .bQ------._.._-____._-.___.._ Water Supply: Public.systern E]. Community system ❑ Private Depth Water Table ------_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam fff Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date----------- --------) No El." New`Co'n'struction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic +ank or cesspool permitted if public sewer is available within 200 feet.) r •; . i Septic Tank: Distance 4}m nearest well-________________Distance from foundation-------------------Material-.........-........-........._.......o-.-------- ❑ No. of compartments--------------------- ----Size--------------------------------Liquid deph--------------------------Capacity----------------------- Disposal ----------- --------Disposal Field: Distance from nearest well-----------------Distance from^foundation--------------------Distance to-nearest lot line......------..... El Nu - F mber of lines.--- .=---------Length of each line-----------------------------Width of trench-.----.----------------.----------- - Type of filter material-------------------------Depth of filter material-------_.------. -----Total length-----------------:----------------- ..----? Distance to nearest well------f n_�.._Distance fro foundation_--/_0_I...._._.Distance to nearest lot line--- SJ...... F ��_ Number of pits------�-------------Lining material_- _-- ---------------- -.. - �-----Size: ��x-��----.Depth Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material------------------------------------- :: i ❑ Size: Diameter--------------------------------------De th----------=--------------- -------------------=-----Liquid Capacity- --------------------------gals. 9' Privy: Distance from nearest well.................................................Distance .from nearest building.----------------------------------------. ❑ Distance tO nearest'lot line---------- --=------------------------------- ------------------------------ ------•--------------------------- -------------- --------- Remodeling and/or repairing '(describe): ----------------------------•--------•--------------------------------------------------------------'---------- . N I -------------------------------------------------- ---------------'------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsLnd ules and regulations of the San Joaquin Local Health District. (Signed) r ContractorM 1: M By:------------- ---- ---/--------- [Title} (Plot plan, showing size of lot �locittion of system. in.relation wells, buildings, etc., can be placed on reverse side). r� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - -------------------------------------------------- DATE .---------- REVIEWED BY----- -------------------It----------------------- --------------- ------------------- ----------------------------- --- DATE--------------------- ------- ---------------------------- BUILDING PERMIT ISSUED---I.i-------------------------------------- --... DATE------------------------------------------- ----------------- Alterations and/or recommendations-- ------------------------ ---------------- -----------------------------------------------=---------------••--------•------------------- ------------ ----------- ------- -----•-=------- ------,-----------•-----------•-------------- -------- ------------•-------------------- --------------------•-- ----------------------------------------•------------ -1 , ----- ---------------------------------r ------------------------------------------------------------•------------------------ ---------------------------------------------------------------...-------- ------------------------------------- -- ---- -----M--------------------- ....... ------------•------------------------------------------------------------------------------------ �fi ..�:, FINAL INSPECTION BY:.,ri�=r� -- �- � Qate-.?-- -J�--------/------ � --------------- 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 FS 4 REViSED 8-59 31A 3-'63 F.Pi11.00. 4 1f