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FOR OFFICE USE: --------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._:_ a.Q?. ..., (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 w jf) rVA14sc ed. This application is made in compliance with Cnty,Ordinance No. 549. r JOB ADDRESS AND �_OCATION----------------- -- �-'-"`------� --- ----�I �` Owner's Name---IC- -----�,-�------ I14-p �?. ?✓ f Phone Address -- - - ----• R-0------------- ------•----------------------------------------•----------------•-.-------------- Contractor's Name-------------- e` �r'---•• ----------- Phone.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J--- Number of bedrooms .—I-- Number of baths -;L.—Lot size ---A.-40__")(_-a'__0._0__________________ ,r Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .-- _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A Hardpan ❑ Previous Application Made: (If yes,date-----------,........) No ❑ New Construction. Yes ❑ No ❑ FNA/VA: Yes ❑ No ❑ i 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___�../_____Distancefrom founclation__._I�__ .....Material----- ____ _ ________ VNo. of compartments----------r�..........Size---- __ ______________Liquid depth---------�I(__---------Capacity_..��- .---- Disposal Field: Distance from nearest well.__'-51"_-__Distance from foundation—/If—`_____-Distance to nearest lot line__ Number of lines------ ---------- Length of each line-------7 -- -i �----•----Width of trench--------- - ---------------.--- r T ri Type of filter matenal-----/�-- --_----- -Depth of filter material_QA._______y___-Total length______a2_5�,0___ _---------------- i1 Seepage Pit: Distance to nearest well.___------_-----------Distance from foundation----------------___.Distance to nearest lot line_____._.-__-__.__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------..Depth-----------------_ --------------- Cesspool: Distance from nearest well-----------------Distance from foundation---.---------------.Lining material-----------------------_-------------- Size: ________. _-- Size: Diameter--------------------------------.--.-Depth---------------------------------------------------Liquid Capacity.----------------------------gals. Distance from nearest buildin Privy: Distance from nearest well g ❑ Distance to nearest lot line------------------------------------ ---------- -•-------- -------------------------------------------------------------------------- Remodeling ---•----------------------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 Z ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ` (Signed)------------------- - ` "-y' -- --- -- ---------- -----------------------------------------------------------------(Owner and/or Contractor) BY ---------------------------------- -------------•----------------------- --------------------------------------------(Title)- ---- (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc., can be placed on reverse side). .S fl FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------- ----- ------------------------------------------- ----------- DATE-----------•------------------------------------------------ REVIEWEDBY---------------------- ----------------=------------ ------------------------------- ---------------------------- DATE-------------------------------------- ------ -------------- BUILDING PERMIT ISSUED---- ------------------ ------ DATE-------------------- Alterationsand/or recommendations:-------------- ---------------------------------------------------------------------------------------------•-•----------------•------------------------ r -----•------------ ----------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ----------- --------------------------------------------------------•---------------••-•--------------------------------------•--------------------------- -------------- ----------------------------------------- ------------- --------- ----------------------------••------------------------------------------------------------------------- -- ---- FINAL INSPECTION BY: `_� � Date--- -l. - - --``----`------ - ------- ------- 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 CS 9 REVISED 0.59 3M 3-'63 F.PMD.