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FOR OFFICE US ;..� y------------- ------- ------- -------------------------------- - - ----------_-`----__. APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) __ _ __ ____________ ___ This Permit Expires 1 Year From Date Issued Date Issued __ _ _ _ __ . FF t g Application is hereby made to the San Joaquin Local Health District for a permit to c;)n r and_in al the work he ein destri ed. This application is made i compliance with County Ordinan No. 549. F7 4,4 S. A�. A5 .s-r--W��. JOS ADDRESS. AND LOC ION- _._------- ----- -------------- ------•------------ Owner's Name-----: ----+ ---- ----- :_._-"��-_�'`. -----------------------------------------------------t� 1'— - -------- Phone------------------------------------ ------u " � /} ----- Contractor's Name--------- ----C�_��J.�2�--- "�4 �+' � [ -------- Phone----•-----•-•-•---•---------------- installation will serve: Residence Apa 4nent House El Commercial ❑ Trate r Court ❑ Motel ❑ Other ❑ Number of living units:oillumber df bedrooms ._ Number of baths /_ Lot size --------�!- ___, ___-a64r_ ______.__.__ i / Water Supply: Public system El Community system (]--,,Private ❑ f Depth to Water Table la- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ C.ay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date---------- "No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No [�]� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) Septic Tank: Distance from nearest we __ _____Dis#ancErfror n on__Ie___-_.__._.Ma riipi____._r �Q�- No. of compartments__-- '_'___'.____ Size_ . _____ ._ _Liquid depth------ ----._.___._Capacity---- �Q 13 Disposal Field: Distance from nearest ell_________________ isfanc e from ._ yD__-__ LDength of each line ation___/0.-1 to nearest I AP_-- --Width of trench------- hCS Number of lines----'---- - --- 7rf ---.--•------�---------- Type of filter material- ► Depth of filter material--------l�_______-Total length_______-_�f p----------------- Seepage Pit: Distance to nearest well-----------------------Distance from foundation___________________ Distance to nearest lot line__.__.___________ ❑ Number of pits------f---------------Lining material..---------------------Size: Diameter------------------------Depth_.__--_.------------------------- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- 1 ❑ -------------------- p ------------------.--Liquid Capacity- --------------------------gals. Size: Diameter-------'--------- -De Depth --------------------------- - Privy: Distance from nearest well--------------------------_----------------------Distance from nearest building---.---------------------------.---------- �y. ❑ Distance to nearest lot 1ine------------------------------------------------------------------------------------------------------------------------------------------ "7 Remodelingrand/or repairing (describe):--------------------------------------------------------1•---------------------------------------•------ -------------------------- ---------------------- ---, --- ------------------------------------------•---------------------------- -_ ------------------------------------ -------------------------------------------------•------------•------------------------•------------------------------------------------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanyes, Siftto laws, and rules anregulations of the San Joaquin Local Health District. (Signed) -------- --- ---•- -----------------------------------------------•--- -------(Owner and/or Contractor) -- ----------------------------------------------------------------------------- - ----(Title)--------------- -------------- -I----------------- ---- --------- (Plot - (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------------- l/ fi G DATE--------- REVIEWEDBY--------------------------------------------------------------------------------- -------------- -------------------- DATE------------------------------- - - ------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------- Alterationsand/or recommendations------------------------------•------•---------------------•----------•----------•-----------•----••------------------•----------- --------------------------- ----------------------------•-----------------------•-----------------------------------------------------------------------------------------------------------------•--•---- ------------------------------------------ ----------I------------------------------------------------------ ---------- -------------------------------------------------------------------------------------------------------------------------•--------- --------- --------------------------------------------------- ---------------•------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY----------- ----------------------------------------------------- Date------------------ ----------------------------- ----------------------------- 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 ES 9 REV4SED B-59 3M 3-'63 F.P.Ca.