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FOROFFICUS : _ {� D 2, - �/-------- S c.t ` -------- -------- ------ ------------ APPLICATION FOR SANITATION PERMIT Permit No. .- �� 1..�' ----------- -------------------------------------------- (Complete in Duplicate) - ------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ... .......6/ 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 o. 549. JOB ADDRESS AND LOC TION + � Owner's Name--- Phone -•---------------------•--- ---------------------------------. ....--- Address ...... -_-- Contractors Name -.................................................... Phone-------•--•-----•-••---•---------•- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j--- Number of bedrooms -/I_—._- Number of baths _f_-- Lot size ----------------------------------- Water Supply: Public system ❑ Community system ❑ Private'0"'Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date--------------------) No RRI"`New Construction: Yes ❑ No [P1`_F_HA/VA: Yes ❑ No Et' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se is Tank:✓ Distance from nearest well-----------------Distance from foundation_- ---------------Material_--.-..__-_--._..-._--_----------___._-----.---. No. of compartments------------ ---- Size.-_---___-.____ --Liquid-depth--------------------------Capacity----------------------- Disposal field: Distance from nearest well--- Distance from foundation--a2v!-----Distance to nearest lot line_�?o_____ Number of lines--------/----- f Length of each line__-_ ___� p Width of trench. Type 'of filter material/ ��.___Depth of filter material---/jp- -_-- _.,-Total length-------- __________________________ Seepage it: Distance to'nearest well--- from fo dation___ �_ D sta ce to nearest lot line=_ `f f �r [ Humber of pits---- --------------Lining material__ _ __-_Size: Diameter_ -..._::.---Depth_,-�..��-._...--.-__. -.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material ..-------------y ❑ Size: Diameter---------------------------- -------.Depth---------------------------------- -----------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well _-..- ------------------------------------------Distance from nearest building-------------------------- El Distance to nearest lot line------- -------------- --- -----------------------•----------------•------•--------------------- -------------- Remodeling and/or repairing (describe): ------------- -t - r--------------------- ----; ----------------------- --- ------------------------------- ---------- - -- - - - - --�4. r _ - -------------------------------- ---------------------------------------------------------------------------------------------------- ----------------- ---------------------------•-------------------------- 1 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 and regulafioqs of the San Joaquin Local Health District. (Signed)---------------------------- ✓.. -- -------------------------- ----------------------------------------- �r Contractor) BY: --------------------(Title)--- ------------------------------- (Plot ----------- -- -------------- (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). t l FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------j� -- ---- ---- = -------------------------- DATE__ -"---- `— - --- ------------------ REVIEWED ---------------- REVIEWEDBY------------------------------------------------- - -------------------------- ---------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------------------- -------------------------------•----------------------------------------- DATEN--------------------------------------------------------•. Alterationsand/or recommendations--------------- -------------------------------------------------------------------------------_----------•----• ----------•-----•--------- ----------- - ------------- 1�-- ---t---------"T�./ = fir' � �L/ Ja C:.,,. .wT ss�' f '+ f / - -----------------------------------X~...Aw--.----------- ----------------------------------------------------------------- - - - -------------- ------------------------------------ ----------- -- ------------------------- - FINAL INSPECTION BY:.------ ---- -------------------------------- Date---.. ----_--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street i <124 Sycamore Street! 205 West 91h Street Stockton,California Lodi,California i Manteca,Cafifornia Tracy,California ES-9 REVISED 9.59 F.P=.2M 6-6a