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FOR OFFICE USE: 14164-----------m------- -- APPLICATION F(N -SANITATION PERMIT Permit No. ----------- --------------------------------------------- {f (Complete in Duplicate) - - .- Date Issued r------ ----- This Permit Expires 1 Year From Date Issued ►. 1_ ------------ ------- --------------------------------- -- — . 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. =--- ----=------- -------------•------------------ �/ r JOB ADDRESS AND L CATIO -- " -- - -T- ------- ---: -----------•-------"---- - , ___ __. - Phone---------------- ---------------- Owner's Name --•-•---•--------------........... Address------ ,_ - Phone. Name___--___-- p = - ---------------- Contractor'sInstallation will serve: Residence �A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ rooms -- Number of baths _/__ Lot size _4 VV,;-•- ` ----------•--------------- Number of living units:._-_ Number of bed Water Supply: Public'system U?<ommunity system ❑ Private ❑ Depth to Water Table %ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [IClay ❑ Adobe[lardpan F] No � -----.-] No � New Construction: Yes ElNo FHA/VA: Yes El Application Made: (If yes,date............. , TYPE OF INSTALLATION AND SPECIFICATIONS: (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----------------•-=-ia--------_-- Liquid depth Capacity Disposal Field: Distance from nearest wek__._-!"~_..-.Distance from foundation_.-"11--------Distance to nearest lit - line_------ Number of lines-"------ ----�..- ----- Length of each line-------------------- --------Width of trench.....j-____---.-- -------- De th.af filter,material-___ _- _/'_"_.-_Total length__--____ _ Type of filter material_ - - --- P "" -- ------------------ T- - 7 Distance to nearest lot line-"_______________ ee age Pit! Distance to nearest well______________________Distance from foundation____.___..__ Number of pits----------------- --- Lining material----------------- -----Size: Diameter----- Depth c Cesspool: Distance from nearest well_________________Distance from;foundation___-__------ Lining Capacity gals. { ❑ Diameter. == --------- Depth---------------------------------------------- Size: - q P tY r .-;'__..__ __ _-_Distance.from nearest building.""___."--------------------------------- I Privy: Distance from nearest well- Distance to nearesfi:lot line----- - - -------------------------------=------------------ ------- - Remodeling and/or repairing (describej:------- y i ----------- ----------------------------- r ;: - = -•--------------------------- ---------------------------------- = -- ------- ----------- I hereby certify that I have prepat'ed this application and,that the work will be done in accordance with San Joaquin County ordinances, State laws, and r les and regulations of the-San"Joaqu'in'L"ocal'Health District. i, C t actor] 7 K�� - ----------------- �or on r (Signed)--------_------- �. - ----------------------- hd- sY [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 + I � �- ---- s------------------- APPLICATION ACCEPTED'BY___-- . -- ' ------------------------------------- DATE__ ` ,- ( REVIEWED BY----- - ---------- ----------------------- ------- DATE--------------------------------------------------•----- .. - E ,,: ----------- -----•---- DATE-------- -----•-- - ---------------------- ---------- -- BUILDING PERMIT ISSUED--------------------------- - ------ ----- __� ;t I Alterations and/or recommendations:------ - - ----•-----•--------------------------------------- ----------------- --------------------- I --------------=---------------- ---- ---------- ----- ---------------------------- _"_.--------------------------.-.-__ Date"- .-------- /_ ------------------------- FINAL INSPECTION BY:.......X �------)SN --- - JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 wast Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Jodi,California Manteca,California Tracy,California E5 9 REVISED 13-59 3M 3-•53 F.P.CC.