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FOR OFF CE SE. _ \� , ✓' APPLICATION FOR SANITATION PERMIT Permit No. a ..f ---------- / r1� ------ --------------------------------- -•-=3G% (Complete in Duplicate) _____ ` This Permit Expires 1 Year From Date Issued Date Issuee?i�...._._ A3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 86cribe#--3 This application is made in compliance with j�Cjjounty Ordinance No. 549. / JOB ADDRESS AND LO �ON 1_-fx- I � -//e?.aP -------------------------------------------------------------------- ------ Owner's Name ie. /, /9a ' -------- 4 Phone Address............---•--•----•....... ... ... �{ �. �-E Contractor's Name-------- •- -------------------------------------------- Phone ,. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms/-____-_ Number of baths _/-__ Lot size _ __, - `- --------------------------- Water Supply: Public system ' Community system ❑ Private ❑ Depth to Water Table4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand oam E] Clay Loam E] Clay ❑ Adobe lardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes -] NoA/VA: Yes ❑ No Q' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 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---------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- i ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------.,--.------.--------_.- Type of filter material-------------------------Depth of filter material.----------------------Total length.................................J------ Seepage P' . Distance to nearest well______________________Distance from foundation�l�_�...__..Distan a to nearest lot lin J _____..... Number of pits------f__.___---.-_Lining materiaLYD-of/C'___-Size: Diameter�__.� _.__.-__-Depth__6).,�7- Cesspool: Distance from nearest well-------------_...Distance from foundation--------------------Lining material-._____--_--____.-___-__-______-___--. ❑ Sizer Diameter------------------------------ -------Depth--------------------------------------- ------Liquid Capacity.-----------------........gals. Privy: Distance from nearest well---------------------------------------_---------Distance from nearest building.__..________-__-_-.--------____.---_____. Distance to nearest lot line--------- ______ ____ __._._____ --- Remodeling and/or repairing (describe):------- ----L - ------•-------------------•---------------•----------------•-•------------------------------------------------•---------------------------------•----------------------------------------------------------------------------- ------------------------------------------------------------- ------------------•----------------------------------------------------•------------•---------•---------------------------------•---------... I 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 s d re a 'ons of the San Joaquin Local Health District. (Signed)------------------------ --- -- - ---------_------- -- -- ---- �-----( and/or Contractor) Owner and o ----(Title - - ------------ BY: =-••-•-- ----- ) (Plot plan, showing size of location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- f ----------------------------------------------------- DATE.........lr--� ..'4..= ------------------- REVIEWEDBY-------------------------------- ----------- ------ ------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------------------------------------------------------------- - cDATE ?-'--=-----r--=--`--'--{--_-'-�----t---t---G--------f-;;�`-------?---------- ------------- ---------------- Alterations and/orf recommendations:-.._-__ -� -- - - - ------------------------------------------ _ ------------------------------------------------------------------------------------ --------------------------------------------------- 4 FINAL INSPECTION BY:------- - �a L_3--------------------------- ----•---- 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 S-59 3M 3-'63 F.P.CD.