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FOR OFFICE USE: ----------- APPLICATION FOR SANITATION PERMIT Permit No. .... ............... ---------------------------- ------------------------ (Complete in Duplicate) Date issued ------------- This Permit Expires 1 Year From 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. 549.4 ,,� Q ( JOB ADDRESS AND LO AT10N - 'lam- ¢ Ate , j Owner's Name------------- _ Phone-----•--------------- - -- -- --•------ -- -- -------------•-------- ---------,---------------------------------- l ?3 Address--------------- --� -------- --- --------7 -�--------------- --- -------- ---------------------------- Contractor's Name-----------�r - ----�..</-r---=--------------•------ _•-------•----------------------------------------------- Phone----------------- ----------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/.--- Number of bedrooms A__ Number o aths...�__- Lot size ---------------------------- Water Supply: Public system El Community system ❑ Private Depth Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel (] Sandy Loam [Clay Loam [❑ Clay ❑ 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 sewer is available within 200 -etj Septic ank: Distance from nearest wel l__,_' --'r�Distan`e ffTm f unda ig Mat-riaL__--� No. of compartments---------2 Size-- Capacity f --- _ qp ------ - Dispos Field: Distance from nearest well.��Distance from foundation____ ___.Distance to nearest lot line-S______.___-_ Number of lines---.--- Length of each line_ �Q_`_"-GQ_.`Width of french------�-/-------------------- Type of filter material--__14- 9---p ____ __ _.t___Depth of filter material----•1__�{�'"_------Total length-_-0;L$ j0/-----_____________ k Seepage Pit: Distance to nearest well----------------------Distance from foundation-------- ----------Distance to nearest lot line__.__.____.______ ❑ Number of pits----------------------Lining material-----------------..... Size: Diameter-----------------------Depth----------._--.--.--------------- Cesspool: Distance from nearest we}l-----------------Distance from foundation--.---------------- Lining material__._..._----____________._______.._._. ❑ Size: Diameter--------------------------------------Depth-------------- ------ ----1----Liquid Capacity----------------------------gals. Privy: Distance from nearest well _______________________-__-___.__._Distance from❑ dearest building----------------------------------Distance to nearest lot line---------------------------------------------------'-------------------------------------------------------------------- ------------------- Remodeling and/or repairing (describe)--------------- ----- -.,--------------------------------------------------------------•-------------------------------------------------------- -------------------------------------------------------------------------------- ------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------- I -------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State 41aws, d. rules and regulations of the San Joaquin Local Health District. (Signed} - ---- --- ----- --- end/or Contractor) By-------------- •-------• - - - -- --- _ (Title)---------------------------------------------- ----------------- (Plot plan, showing size of lot, location of system in relatio o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ -------------- DATE--------"L-. S - ---- -------------------------------- REVIEWEDBY-----------------------•---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------- ---•------------------ `------------------------- DATE.--------------------------- ------------------------------ Alterations ---- - -- Alterations and/or recommendations:-----------------------------------------------------------------•-------------------------------------------------------•------------------------ -•-------------•---------------•------------------------------------- ------- ------- - -------------------------------------------------------------- -------------•--••-------------------•------------------------------- -------------------•----------------------------------- ------- --------------------------------------------------------------------------------- ---------------------------------------------------_------•---------•--- ------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- --------------------------------------------------------------------------------•--------- --------------------------------------------------------------------------------- FINAL INSPECTIONBY:l� -----------------------h SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California L CS 9 REVISED 8.59 3M 3•'63 r•P.CD. ry