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FOR OFFICEUS : 3 i �� ,_. __.._.---_ -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . d....... --------------------------------------------------- -- (Complete in Duplicate) Date Issued _______.11 __ This Permit Expires 1 Year From Date Issued � Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with Cou y Ordi�naJnce No. 549. JOB ADDRESS AND LOCATIO _._ __. �J(��---•--------------------------------------- -------------•----••-----------------.------------------------.. Owner's Name-------- -- ---- ' .. Phone----------------------------- Address ----- ........ -- -- ----------- ----------------------------------------------------�. Contractors Name Phone. .............. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El Motel ❑/ Other Number of living units: -------- Number of bedrooms __;?� Number of baths J.. Lot sizere�C-e4{ ---------------------- Water Supply: Public system 2`Community system El Private E] Depth to Water Table We t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E<Hadpan ❑ Previous Application Made: (If yes,date----_--------- -----) No ®OOO'New Construction: Yes ❑ No H+—FHA/VA: Yes ❑ No 9j— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic.TanIq Distance from nearest well---------------- Distance from foundation--------------------Material.------------------------------------------------ .,Aor f No. of compartments---------•--- -- --------Size-------------------------------Liquid depth-------------------------.Capacity iyld: Distance from nearest well ________________Distance from foundation--------------------Distance to nearest lot line----------------- i A5VI-/AJC Number of lines---------------------=-------------Length of each line------------------------------Width of french---------•---:-----------------_--- v ` Type of filter material-------------------------Depth of filter material....___..._.____rTotal length _____-. Seepage ! {" � Pit: Distance to nearest well___`_ ______Distance fr m foundation_. _r '.Dist n� to nearest I t li e...t....__ Number of pits.---/-______________Lining maferial__ _�__Size: Diameter__I� _.--._-__--_Depth_ __... . Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material.-._--_.____._-.___-.....-_._-_.._... ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----.-------•------------gals. Privy: Distance from nearest well---------------_____-----------------------------Distance from nearest building------------.--------------------_--___._. ❑ Distance to nearest lot line------ ------------------------------•------•------------------ --------•---------------- I Remodeling and/or repairing (describe :----------------- - --------------------------------------------------------------------------•---------------------------------•---------------------------------------------------------------------------------------------------------------- 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, and rules andre ulations of the an Joaquin Local Health District. (Signed)----------------------- -- - -----------_-----------�or Contractor( ------------- By:-------------------- - --- - - -------------------------- - > (Title) j°----------------- -------------- k' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPAR MENT USE ONLY ---------------- APPLICATION ACCEPTED BY-- - --------------------------------------------- DATE.... 7 �Q REVIEWEDBY----------------------------- ------------------------------------------ DATE-----------•------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------- -----------------– DA•TE--- -------•-------------------------------------•---------•- Alterationsand/or recommendalions---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ -------------------------------------------------------•------•------------•-----------•---------------------------...------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- - ----------------------------•----- ----------- -----------•-•-------------- --- ----------I----------------• ----------------------------------•----------------------------------------------- ------------- FINAL INSPECTION BY: - �� --------------------------- Date---------4----'--1 ......• t'---,--------------------------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lotti,California Manteca,California's Tracy,California £0.9 REVISED 0.59 F.P.CO.2M 6•E0