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FOR OFFICE USE: ------------- ----- ------------------------------- -- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No- -_----- I.......... ------------------------- --------- ------------------ "--- (Complete in Duplicate) - Date Issued .-_•____,_.___Y_/�� -------------_------------_-----------------_--------- ___ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein descrilaed'J This application is made in compliant with County Ordinance No. 549. JOB ADDRESS AVvl LOCATI - ! F ... °'�7------------ `j``��AA Owne'r's Namev!!L -xa Phone.. t f Address + x q # V------ --•------------=-- r .---- ------------------------------------------------------------------ -:------....F r c Contractor's Name----------- ------ • -�----�--------- ------ ----- --- --- ------ ------- ...- •--- ----••------- Phone.-------•-•----------------•------- Ins+allation will serve: Residence pp Apartment House ❑�,Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -----S._ Number of bedrooms ---;; �umber baths __/-__ Lot size ______ : -_. ________________ Water Supply:I : Publicsystem ElCommunity system [3Private d De pth ._Water Table __--__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date_____________________l No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------............... ❑ No, of compartments--------------------------Size--------------------------------Liquid de p�h--------------------------Capacity------------'---/-- ,1 f�___...__.Distance to nearest lot�ine__:_-r`_______-__ Disposal eld: Distance from nearest w II-,��-_-_-_Distance from foundation____ _. � Number of lines________________ ____ _ ____Length of each line--------�` _Q___�r_._.Width of trench.... ..___�___._____._______.-- T e of filter material_ d__. ____De th of fiiter material____ _ __ Total length-------�1�!`________-----___________ Yp ` P �� ,� Distance to nearest well_.,._�J _____.____Distance fr fo ndati -z._1_6___--__.DLs ance��``tonearest lot ling__-__r _�._ Number of pits--------/-----------Lining material-- --.Si--. 9iameher�_�__/_(�_-Depth____,�----------------------• 1 Cesspool: Distance,from nearest well-----------------Distance from foundstion------------------- Lining material----__________.____.__.______________. ❑ Size: Diameter_:------------------------------------Depth---------------- ------------------:---------------Liquid Capacity----------- ------------- gals. .� Privy. Distance from nearest well--------------------------------------------------Distance from nearest building----------.____________,________._.___._. ' CDistance to nearest-4qt line-=--------------- -----.-----------------------r-------. ------ ---------------------------------------------"-------------------- r4 :... • 5 1 - - I Remodeling and/or repairing (describe):""___..__ ___ _______ _ ________ r { _ i ' I __ r �..__ ____ _ __ _ ____________________________________.______-_.______________-____'___________________._.__.__._________--.__________________.______________________ -_ ______.______-.--___________.________--.-____________...._____...__._ Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la nd rules an regulations of the San Joaquin Local Health District. I (Signed)--------------- ----------------------- - -------------------- -------------------(Owner and/or Contractor) 2 1 " ---- BY: f ------(Title)-- -- ------------ ------------ ---- ------------ = (Plot plan, showing size of lot, location of system in relati to wells,.buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- _ ---------------------------------------------- DATE---- _--/ 1" . --- --------- REVIEWEDBY--------------------------------------------------------------- --------------------------------------------------------- DATE----------------------------------------•------------------ BUILDING PERMITISSUED------------------------------------- _ - DATE-------------------------------:.---,----------------- <Alterations and/or-recommendaticris:`_ ------------------------- ------------------------------------•-------------------------------------- -----------------•- - ------------------ - ----- ---------------------------------- ------- -------- _ # } 3 I FINAL INSPECTION BY:.. ----- ----------- - ---------- Date- a "'0 -------- -----•- --- -------- ---------- -"----------------- 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 6-59 3M 3-'63 F"P.DD.