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F,OR OFFICE USE: C_ ----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Perm;* No. _. ----- ---------- -- -------- -- --------- ------ (Complete in Duplicate) Date Issued ___..__-______________________________._.____._-.___.--. This Permit Expires 1 Year From 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. 1 JOB ADDRESS AND LOCA N _ t __Z,..--a��------------------------------------------------------------------------------------------- Owner's Name Address-- _.,w -•------------------------------- --------------------------------- Phone------------------------------------- ----------- ----- Contractor's Name_-------- - ----- -------- = Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _._l_ Number of bedrooms . _ Number of baths.___ Lot size __ __ Water"Supply: Public system Community system ❑ "Private ❑ Depth to Water Tablepft, Character of soil to a depth of 3.feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay;❑ Adobe 23--'Hardpan ❑ f Previous Application Made: (If yes,date------------------- ] -No I New Construction: Yes ❑. o FHA/VA. Yes ❑ No -- TYPE OF .INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted_if-public sewer is available within 20_0 feet.) Septic, `Tank; Distance from nearest Well)--------------Distance from foundation--------------------Material'-_-_._______._______-__--._-.___._______--__ � No. of compartments ` • Si,,--- -------- -----------------------------Liquid depth-------------''--+�-------Capacity-------------------- Dispesal Field: Distance from nearest well_-----------------Distance from foundation--------------------Distant e`to�nearest lot line_______________-_ ----------------Length of each line------------------------------Width' o414rench-------------------- - C� Number of lines_________________ _ ___- "_____"- Type of filter material-------------------------Dept'hi of filter material------------____--_----Total .length------------------ --------------------- 4 i l f j J, 04 Seepage Pit: Distance to nearest -------------______Distance from fo ndation___ 6__'i_-----.-_Distance to nearest lot line-lop--------- Uf [�r Number of pits._. '--------------Lining Size: Diameter-_. De th_ �--------------__---• Cesspool: N Distance i rom nearest well-------------- -_Distance from foundstion___._._._____:___._-Liningl ❑ material-_._._____.__-__.__.____._____-.__-__. Size: Diameter. _-- --------------------De th -------------------------- --------- ------Li uid Ca acitY -- gals. , Privy: Distance from nearest well_______-------------------- ------------------�-_Dis anc'e from nearest building------------------------------------------ F1 Distance to nearest lot line---------------------- -i :� 3 k O i. -------------- ------------------------------------------------- ---------------------------------------- Remodeling and/or repairing}(describe): ¢�� s '' -----•---f------------------- -- ------------------- 1 I I �} X.. ------------------------------------------------ -------------------------------------------------------- I hereby certify that I have.-prepared this,,-appIication_and4hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District.- _ } t (Signed) ------ ---- --------------------- ( ,Lor Contractor( By: -'---------------------------------=--- "`__{ritlel= - ------- - -- ------------ / 2 - (Plot plan, showing size of lot, location of system in relatio wells., buildings, etc.., can be placed on reverse side). FOR DEPARTMENT USE,ONLY ` APPLICATION ACCEPTED-BY"'- • `- ------------- ---- ------------ -------�-"-C----------------------�--- DATE------------- ,tit -------------------- REVIEWEDBY------------------------ --•--------16=-------------------------- ------ --- ----------------------------------- -•------- DATE BUILDINGPERMIT ISSUED---------------I------"------------•------"---------------•------------------------ --------------- DATE--------------------- Alterations and/or recommendations:'__-_..__.___ 1 _ -"----------------------------------------- ---------------•-••--------------------------------------------------------------------------------------------------•---- ----------------------------. ------------------•---- I -----------------------"---•----•-"--•-"------"--------•--------------•- ------------------------------------•--•----••------------------------- -- -------------- --------------------------------- --------- - ------------._.__-_____- FINAL INSPECTION BY:----- -�------ Date------------ ---{-->� SAN JOAQUIN`L4,CAL HEALTH DISTRICT : 1401 E.ffaxelton Ave. 300 West Oak Street 124 Sycamore Street Y 205 West 91h-StreetR- Stockton,California Lodi,CaliforniaManteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'63 r•.PX0. -