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FOR OFFICE USE: ------------- --- APPLICATION FOR SANITATION PERMIT Permit No. /�:� APPLIC i -- ----- --- -- (Complete in Duplicate) Date Issued __.._ .......... _�� --------- pp----------- - -.---- This Permit Expires 1 Year From Date Issue A lication is hereby made to the San Joaquin Local Health District for a permit to ns#rust and install the work herein described. ��_: a This application is made in compliance with County Ordinance No. 49. r � I� JOB ADDRESS AND OCATI.ON=_:'_:,._ - _ .': _:� . - one- _- _ ------ ---- Ph , Owners Na -- --•------ r ---- --------- - Address += r - t - Phone-----------------•----------------- i Contractors Name-------- Inst.allation _.-__--Installation will serve: Residence Apartment Ho se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I � - ---------- Number of living units: ,!-____ Number of bedrooms /� Number o a#hs _�.- Lot size _____ ` + Community'system ❑1,Private Depth to 'ater Table ________ ft. Water Supply: Public system ❑ r dobe❑ Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑'�Gravel ❑' Sandy�Loar�I Clay Loam El A ❑ Previous Application Made: (If yes date_.._______,_.. - -y No ❑ New_Construation:Yes`: ] No E] kFHA/VA: Yes ❑ No ❑ G r,TYPE OF INSTALLATION AND SPECIFICATIONS =�' (No septic tank or cesspool permittediif public'kewer is available within 200.feet]— Septic Tank: Distance from nearest well--------Distance-from-foundation_______------------lvl8i eriaL____---_________-___._-_____. _ ❑ No. of compartments------_-------------------Size-----•--------------------------Liquid'depth- �CapacitY If �.V. _.Distance to nearest lot line____ _ r ��__-.Aistance from foundation___:_ _ d r Dis o Field: Distance from nearest well-� . p -_-___Length of each line__'___ --_. } Width of trench_______ ________ Number of lines-----------�-'-----A'-- � ��-1�f-- -------------- De th of filter material_--_- ---------Total length---____1-0- �-------------------- f+ yp w t t T e.of filter material___ E i {rom foundation_____ ____ ________Distance #o nearest,lot line__.____._____--__ (� Seepage Pit: Distance to nearest well_________ _____ ____Distance ; I ❑ Number of pits------------------ -Lining material---------- ---- = .Size:-Diameter--------- --------•---Depth- f.... Cesspool: Distance from nearest well--___________.:_Distance from foundation-..________________Lining al------ De th - -- -------- ' ---- - Liquid Capacity gals. Jr ` ❑ p --- - Size: Diameter---------------------------------------. Privy: Distance from neaest-well________________________--_______.__-.___._----Distance from nearest building____--___________-______..___-_._____.._. ------------------------------------------ ---------------- Distance to nearest lot line-------------------------------------------------- ---- 1 Remodeling and/or repairing (describe):?-------------- -- ---------------------------------------------------------------I-------- --------------------•----------=--•----------•---------------•-•-----------------------' 6 r C/r 7! ------- ------------'t /-------_-------------- •-------------- ---------------"-------------'-----_ 1 �,--------------- �` '------'--- ------------------------------------------------- •------------------------•------••---•------------------------------------ :__--.----- C I hereby certify that I have prepared this applica ' X nd that the work will be done in accordance with San Joaquin County ordinances, State law , n rules and regulations o e Sa Joaquin Local Health District. F ---- --- - ------------ --------------- rid/or Co ntractorY-, �—,- - tl B = = --------f-----' ----- (Plot plan, showing size of lot,.location of system in relatioOil wells, jAildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__- -- - --------- --- ----------------------------- DATE-- -' - s. ----------------------- REVIEWED BY---------------------------------'------------ ------------------------------------------------------- ----- DATE-------------------:---------------------------------- BUILDING PERMIT ISSUED----------------------- -------------------------------------- -------'--------- ---------- - -------- DATE-- -- -------------'----------------'---------------------'-- Alterations and/or recommendations______________________ -------------------------------- - ------------------- ------------ ------------------•- ------------- - - --- ----- -- ---------------- FINAL INSPECTION BY:__ . +� _ Date - � `�----- --------------- ------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California t:5 9 REVISED 8-59 3M 3^'63 F.P.CD. S