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FOR / E USE---- ___________ ________ ------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. . h.. . -------------- --------- ---------------------- ------ (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---e f 00D--k-----=� ---- ------ -- -- Owner's Name--------- -- ----S- - ---------- ------ -------------- ---------------------------- ---- - -- Phone.----------------------------- Address------------_ - ---Address------------_ 1 Contractor's Name----------------------------f -Z_7. i --------------------------------------------------------- Phone--5�` 41___- -------------- Installation will serve: Residence U�]- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j____ Number of bedrooms __2__ Number of baths --j____ Lot size ---------4_"G__"---6-_�7--_______________"- Water Supply: Public system ffT Community system ❑ Private ❑ Depth to Water Table kl_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe e Hardpan ❑ Previous Application Made: (If yes,date--------------------) No e New Construction: Yes ❑ No R9^FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic ank: Disfance from nearest well_________________Distance from foundation--------------------Material"__.____.________._____.____-_- ------------- No. of compartments--------------------------Size-----•----------------------•---Liquid depth--------------- ---------Capacity----------------------- Disposal field: Distance from nearest well..d_ah-_-._Distance from foundation__/_a------------Distance to nearest lot line___-__.__.__ 00 Number of lines-----------I-------------- Length of each line-------CP---------------Width of french-------2-._-_----------------.--- V Type of filter material___t- - -------Depth of filter material----1_,�-- `{______._Total length__________ __ ____________________ Seep-age Pit: Distance to nearest well__1�a_y*_-?.____Distance from foundation----t_O_"_•_____.Distance to nearest lot line---77 -__- &_ Number of pits------/-------------Lining material----%c.t-----Size: Diameter_._3.�."��___-___Depth__-2.5�---------_--------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------_--------------------------- d Size: Uiameter----- --------- - ----De th--------------------------------------------------._Liquid Capacity---. gals. a, A Privy: Distance from nearest we1-------------- Distance from nearest.building:"__"_______________________________"_. ❑ ,Distance to nearest lot line--------------------------------------------- --------------------- --•---------------------------------- ----------------------------- N .0 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 ordinances, State law , and ides and :regulations of the San Joaq . Local Health District. (Signed f---------------------------------------------------------[Owner and/or Contractor] Br -- Title--- ---- --------- - --- ------- ------ { ) (Plot 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 ------ --- ----- ---------------••----------------------- DATE---- REVIEWEDBY---------------------------------------- = --------- -------------------------------- ------- DATE BUILDING PERMIT ISSUED ---------------------- ------------------------------------ DATE-------------------- --- --------------------------------- LL. - - . .. ._ .. k_ Alterations and/or recommendations:------- --•--------------------------------------- ------•----------------------------------------------------------------------------------------------------- ------------------------------------ --------------•------•-------•---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------•---------------------------------•-------------------•------- ---------------------------------------------------------------- ---------• -•------------------------------------- --- -------------------------- --"--------------------------------- ------ -------------------------- -----•---------------- -------------------------------------------------------------•-- ---------------------------------------- t . JJ11 FINAL INSPECTION BY: - v .. — _ Date------ `l- - (� ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-163 F.P.Cu.