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FOR OFFICE USE k _ - - . ".'. _._____ _ APPLICATION FO SANITATION PERMIT Permit No. i -------------- -- -------- - --...------- (Complete-in Duplicate) -- --- This Permit Expires 1 Year From Date Issued Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 544. W. JOB ADDRESS A LOCATION..__._ .- ..5_.. ---_--.-- _ ------ ------ --- --- - ---------------- ------------ Phone-_ -G-- --------—-� Owner's Name---------- ---- k]--,- Address -----3 -- ....-- Contractor's Name---- ------- ----------- ---• --------------------------- ---- Phone-•-------------------------- - -- ----------------------------------------- ----- Installation will serve: Residence ' [��Apartment House ❑ Commercial E] Trailer Court E] Motel El Other E]Number of living units: --- Number of bedrooms _.:2.__ Number of baths ___t__ Lot size ..__. ..f__4-eAg _- ------ Water Supply: Public system 2' Community system ❑ Private ❑ Depth to Water Table ------ - ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [�Hardpan ❑ Previous Application Made: (If yes, date----------__------- ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: f V (No septic tank or cesspool permitted if public sewer is available.within 200 feet.) t , Septic Tank: Distance from nearest well_________________Distance from foundation__.-----------------Material ___.._____---.__._.___._ ❑ No. of compartments--- . -------• .. -Size-------------------- -------Liquid depth--------- - --------Capacity----------------------- ` Disposal Field: Distance from nei arest well...____...._Distance from foundation---14.{� ___..Distance to nearest lot ❑ ,iL :_„I Number of lines.'--------I?---------------------Length of each line----------- j,T'--------Width of trench.-----�`t • � ---.-.-___.-.----•-- 0, Type of filter material__ .�..............Depth of filter material "��_____-__.__._Total length______ j1__:_ --------------------- Seepage Pit: Disfance to nearest well...._____-------------Distance from foundation-------------------- Distance to nearest lot line________..___.._ ❑ Number of pits...)---------------...Lining material---------------------- Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well ___...._.__ -- from foundation................. ..Lining material_____.______________.______________._. ❑ Size: Diameter- A ------------- ----- ----------Depth-------- -------------- ---------------------Liquid Capacity gals. Privy: Distance from nearest well.._________________________ -----.-.Distance from nearest building-------------------- --------------------- Distance to nearest lot line----.--------------__ - - ------------------------------------------------------ ----------------------------------------------------------- Remodeling and/or repairing fdescribe)_-----_------------------ - 1 ----------------------------------------------- ---------------- I - ---------------------------------------------------------------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 laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ ---------- - (Owner and/or Contractor) I By:------------------------------------------------- ------------------ ---------- ----------- ------------ ---------------- -------(Title)--------------------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------I--- - DATE-------4� ------------------------------------------------------- - REVIEWED BY------------- ----------- ------ --- - ------------------------------- ----- ------ DATE_-------- ------- -- -- ----------- UILDINGPERMIT ISSUED-------- -- - - ----------------------------------------------- -----------_---- ---------------- DA•TE----------------- ---- ---- ------------------------- Alterations and/or recommend at ions:.I-------------- -------- ---- ------------------ ------------- 1 • ----------------------___---------------------------------------------------------------------------------------_........____-------------------------------_-------- ---------------------............................ ---------- ---- _----------------------------------------------------------------------------------- .______.__.. -------------....................................t..__...__..__.----_--------------------------------------------------------------.----------------------.----_--------------.______.___..___...___..____._____ FINAL INSPECTION BY:.. - w ;Date-------------------- SAN ----- ------SAN JOAQUIN LOCAL HEALTH DISTRICT r - 1601 E.Na:elton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. California K_. . Manteca,California r i Tracy,California E.H.92M 3-67 Vanguard Press �,