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FOR OFFICE US . 4 I - APPLICATION FOR SANITATION PERMIT Permit No. .._- _ o...J-__ --- - ---- - ---------- --------------t f / -d4. ---------- } (Complete in Duplicate) Date Issued --------------_-.----------.-- _-:-.___._------__-._._ 'This'Permit Expires ]'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 rdinance.No. 549. JOB ADDRESS AND LOCATIO -------f E��. --- - -'~Pi- = Owner's Name " ----•----------- Phone_....." a , yx Address----....- " --- 1 ------------ -.--- - -------------------------•------------------- •------ -------- Phone------------------ ------------ Contractor's Name------------------- -------------------------------------------------------- ...------ Installation will serve: Residence �Apartment.House ❑/ Commercial ❑ Trailer Court C] Motel ❑ Other ❑ Number of living units:•--`1_.Number_,of bedrooms __f____ :Number of baths .f_.. Lot size --------------------------- sf Water Supply: Public"system ommuriity system ❑ . Private F] Depth to Water Table _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Mader (If yes,date--------------------) No [; New Construction: Yes ❑ No [&sFHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we _s��. Distance fr m foundati -_ on- /440....__.Materja�__ _Y___-_ ___--- �__ __._--. L• �,r ®� No. -of compartments----- -•-----------------SizfJr---- - -_--Liquid depth----��_ �.-.---------Capacity Disposal field: Distance from nearest well------------Distance from foundation---0APIP_ ----Distance to nearest lot line_________________ Number of lines-------1_:_-- _ Length of each line---. �-----------------.Width"of trench--..-,'—.. ---------•-------------- VIP «. st s Type of filter matenaL,�9_V1� Depth of filte materialA_ ______-._.__Total length-------- _�_______________________•-- Seepage Pit:,..- � Disvance'to•nearest well_-'0B__'-�^Distant m foun tion____ ..___ �!�____._..Distance to nearest lot line_________________ j t Number of pits-- -.C----'---------Lining material . __P�!J _ ize: Diameter---- d�..---Depth-. ► ---- ------------- Cesspool: Distance .from nearest.well------------------Distanc oundation._.-________-__--- Lining material------------:-.____________-._-______- K. ❑ _Depth---------------------- ---- -------------Liquid id Ca aci -------------gals. � Size: Diameter__-;_:T------------------ ------- ------ - - q Capacity Privy: ,) Distance from nearest wel-----------------------------------------y-- Distance from nearest building.____.'______--__--___________._______ ... ❑ Distence.to nearest lot1line----- ------------------------------------- ------------- ------ -------------------- ----------------------------------- mo ell ar�d/or reg ringq scr-ibxi-, l�r --------------------------------------------------- � -- ------ - • � --- --------------•--------•------------------•----•--•-----------------------------•---------------- ------ ________ 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, ajrules d regulatiioonJs of theSan Joaquin Local Health'District. -Si ned -- - ----------- - {Owner and/or Contractor) /�BY:---•--------------• ---- 6 -- o------- _---------------- --- -- �'u(Plot plan, showing size oion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �� -------------------- ------------------------- - PATE � -2--3- APPLICATION BY------------'--------- ------------------ --------------------•---------------------------- DATE.. ........ -------------------------------------- BUILDINGPERMIT ISSUED------------- ------------------------i------------------------------------------------------------ DA4TE----- ----=--------------`---------.....----------------i-- Alterations and/or recommendations------------------------ ---------------------- -----• -------------------------------------------------- ------------ - ------------------------- - � = = �! - ----- ----- -------------- .- ---------------------- E �l z = — x ----------------------------------- Date - - — --A#-- ----------------------- ----••- --- ----------- y o--i X FINAL' INSPECTION BY,--"-. -------------------- Date t f SAN JOAQUIN LOCAL HEALTH.DISTRICT 130 South American Street 300 West Oak Street _ 124 Sycamore-Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6-9 REVISE0 9-59 r.P.CO.2M 6-60