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FOR OFFIC U E: v - ------------"---------------- ------------------- ------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No......... -------------------------------------------- (Complete in Duplicate) --------------------------------------------------------- This Permit Expires 1 Year From Date Issued 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. JOB ADDRESS AND LOCATION._ Z_ - Owner's Name------------ .... – �- --- ------------------------ Phone ------------------------------------ --------------------- Address ------------- Contractor's Name .......................... ..•- --- Phone---..---.-_.-- ............................................. Installation will serve: Residence g 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.___ Number of bedrooms _A Number of baths __/___ Lot size _---___________________________ Wafer Supply: Public system [Community system ❑ Private ❑ Depth to Water Table --Wt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adore Rr"Pardpan ❑ Previous Application Made: (If yes, date -------------------- ) No RK New Construction. Yes ❑ No g;r FHA/VA: Yes ❑ No R;.— 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_-__-_-.__--__--______-- ._---------__________- e,M'r�y-/4/ No. of compartments -------------------------- Size -------------------------------- Liquid depth -------------------------- Capacity. ...................... Disposal Field: Distance from nearest well_________________ Distance from foundation -------------------- Distance to nearest lot line ----------------- Cx� Number of lines ------•----•---- ------------------ Length of each line ------------------------------ Width of trench ----------------- ----------------- .. Type of filter material -------------------------Depth of filter materia!__________________ -____Total length___________-___-_____________--__________- �. Seepage Pit: Distance to nearest well ----- 7=7T! -w ----- Distance from foundation ---- Ze____--. Distant to nearest lot line _�x_.---- Number of pits ------ / ------------- Lining material___/-eJPA;4.Size: Diameter__JU..-------- Depth--.t2U�- .____-___-_______ Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -------------------------------------- 0 Size: Diameter -------------------------------------- Depth -----------------------•---------------------------- Liquid Capacity -- ---...........--•--.....gals. Privy- Distance from nearest well ------- ----------- ------------------------------- Distance from nearest building --------_______-_-_________________---___. ❑ Distance to nearest lot line-----------------------�-------------'-------------------------------------------•------------------•------------------- Remodeling and/or repairing (describe________________________{�G --•---------•------•-------•-------------------------•-------------------••----•--------------------------•--------•----------•------•-------- - -------------------------------------------•-•-----------------------------•-------------------------------------- ----------------------------------------•------------------------------------------------------ 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 anregulations of the San Joaquin Local Health District. (Signed)----------------------------- = ------------ • (Owner --w �3ontractor) By:---------------------------------------------------------------------------------------(Title)-------- �. L----- - - ------------- (Plot plan, showing size of lot, location of system in rd tion to wells, buildings, etc., can be placed on reverse side). FSR DEPARTMENT USE ONLY APPLICATION ACCEPTED 1----------------------- -------------------------- DATE ---,M--!------ -0--------•- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE ----------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE --------------------------------------------- Alterations and/or recommendations:---------------- ------------------------------------- ------------------------- --------------------- ,� =.-_------- --- --- ------ ----- ----- .-------- ----------- ---•--•---------.-------------------•------•---------- ---- FINAL INSPECTION BY:- --- C --7-4-D --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wert Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca, California Tracy, California EB -9 REVIBEO 8-59 F.P-Ca, 8M 6-60