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rUK V1,N : Uot: - ------------------------------------------------------- ----- ---- ----------------------- APPLICATION FOR SANITATION PERMIT Permit No. _lf`-�.__� ... --------------------- ---- -------------------- (Complete in Duplicate) ` 1 ------------------------------------------------------ This Permit Ex ires 1 Year From Date Issued Date! Issued --/ � -- 19 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 Ordinan e No. 549. N "7� I sf o r x- Sr x;X s,f • r I . JOB ADDRESSFNDCATIO -: ---,�..�---i -------- -------------- � -------- ----- ------------- Owner's Name = ------------------------------------- --- - -------------------------------------- PhoneAddress-----------• _ -- ------------- ------------------------ !f Contractor's Name---- �C� ��-4.r-- }- + f------ Installation will will serve: Residence Apartment House ❑ C mmercial ❑ Trailer Court ❑ Motel ❑ Other El Numberof living unit-_ Number of bedrooms umber of baths___ Lot size __,� .-_-_ Q- ------.-_ Water Supply: Public system ❑ Community system Private ❑ Depth to ater Table -------- ft. Character of soil to a depth of 3 feet: Sand ] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ obe C] Hardpan ❑ Previous Application Made: (If yes,date--------------_ . ) No E] New Construction: Yes E] No FHA/VA: Yes ❑ No ElTYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ~ Distance from nearest well-----------------Distance from foundation----_---------------Material -.--___-___---------__-_____----- No. of compartments---------- -------- - Size Liquid depth---------- --- -----------Capacity----------------------- a i Distance from nearest waif- ---......Distance from foundation-_- ! _ ��_ --Distance to nearest lo+ m��-I_-�.-_- Number of lines-----I----- --- --------- --Length of each line---7�4 .-- Width of trench____-____.- �.. Type of filter materia �! yp .--- -Depth of filter material-----1- ---__-----Total length---------------------'T---. ----. 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 well-------------_-_Distance from foundation--------------------Lining material--------- ---------------------- ElSize: Diameter----- -------------- ------------- -DePth----------------------------- - ----- ---------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ -IS ❑ Distance to nearest lot line--------------- ------ r,. Remodeling and/or repair' (descri ---- --- ---- --------------- ------- ------- -------:--------------------------------- ---- ------------------ - --------- 1 - --------------------------- ------------------------------ Al-L-70-al --------------------------------------------------------------------------- --- I heXDfy that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancaw-----------------oul and rufes regulat'on of t San Joaqu' cal Health District. N (Signed) ' ' t --------- ner or Contractorl By.: " a-�- (Title) -_- _- -------------- (Plot plan, showing size of lot, location of system in relation t e t, buildings, etc.,can be placed on reverse side). -�- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----.-- ----------- -- ---- ----------------------------------------------------- DATE----------�Y.�'�_ ��1 �------- REVIEWEDBY------------------------- ------ - -------------------------------------------------------------------------------------- DATE------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- -------------------------------- Alterations and/or recommendations:------------_------- --- -- -------------------------------------------------•---------------•-•--------- ----------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ------------------------------------------------ ------- ----------------------------------------- -•---------------- ------------------------------------- -----------------------------------------------------------------------•--------------------------------------- -------------------------------------------------------------- - -------------------------------- ---------------------------------------------------------------------------------------------------------------------- -- Ff NAL INSPECTIO Date------------------ SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California F.P.C C. 1 I