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FOR OFFICE USE: ----- - - ----------------- --- ------ - ! -� ---------------T--H___ APPLICATION FOR SANITATION PERMITPermit No. -------- ------- -----_-- -----. (Complete in Duplicate) 2l Date Issued ._._ d_l-6 // ----- ---------_-----_____.-_-___-_,___--_!------------- 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 instal the work herei escribed. This application is made in complia 'th County rclinanc 549. JOB ADDRESS A . LOCATIO = Y � - - ------------------------ A Owner's Na - ----- ---------- -- ---- --------------------• --•------- ------_ - ---- -------- Phone---------------------------•-------- ----- --- ---------- Addressp -c---------- -----'- r---- - - --•-• -------------- --4---------- -- -- •----- ------------------------•------------------- -- ----� ' i Zr --- •------ I �¢ Phone---"T-`.....4-3 ---- Contractor's Nam� _._!� - .. .i4 � ve�_c ---------- --- Installation will serve: Residence arm nt House ❑ Commercial❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-_1.-umber of bedrooms __,Number of the _-_ Lot size.._____,�.L¢-o.______ __ --�----.----._ Water Supply: Public system ❑ Community system ❑ .Private De;��am� r Table -------- ft. ? Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date----------- .--_...) No ❑ New Construction: Yes ❑ No F1IA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:' i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f Septic Tank: Distance from nearest well_>:�1_____._ Distance fromffoundpation___l0--------Materl---i� _ _ ____________ ____________________ No. of compartments_-_'�_____________Size_° _� _. _ __r�_.___Liquid depth-_--�_ .......... Capacity_._ . Disposal Field Distance from nearest well-_5 - --Distance from foundation.-_- - - istance to nearest lot line___________ Number of lines__-%______---_-- Len th of each lin f __ Width of trench -_-'9 Type of filter material __ __Depth of.filter material__;'-_____-- Total length_44-, ---/ Seep a i Distance to nearest well-------.--------_____Distance from foundation____________________Distance to nearest lot line__-_---______-__ ? Number of pifs------------ ------Lining material-----------.------------Size: Diameter------------------:----Depth--------------R;.-:- - Cesspool: Distance from nearest well_________________Distance from foundation-------------------- Lining material__ ------.----------.------------------ 1771Size: Diameter----------------------------- ----- -Depth--------------------- ----------- ---------------Liquid Capacity----------------------------gals. ��pp Privy: Distance from nearest well ___________________ Distance from nearest building_________________----_____-__--__--____._. 9� ❑ Distance to nearest lot line_'--- ----------------------------------------------------------•- ----------------------------------------------•--•------------------_. Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------- --------------------------------------- ------------------•-••----------------------------------------------------------•-------------------••------------------------- ---------•-------------------------- -------------- - -----------------------------------------------------------•-•--------- -------------------------------------------------------------•----------------------- ------------------------------------ I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin County ordinanceZSala and rul and regu ations. f e San Joaquin Lo Heal h Disfri �l� ---- -- --- ------- - ------- - ------- ---- ��---------( e arc Contractor) (Signed) , ' By:-------------------------------------------------- -----:------------------- ----- � -- ------ - -----{Title)--------------------------------------- --- ------------- (Plot plan, showing size of lot,.location of.system in.relation wells, buildin s, c., can be placed on reverse side). tim FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY--------------- ------ ----------- ------ ��------------------------------------- DATE----------- /t ------------------ REVIEWED BY------------------------•---------------- --- ------------- -------------------:---------------- ----------------- DATE-_------ - a ------------------------ BUILDINGPERMIT ISSUED---------------------------------------- ---=---------–-------------------------------------- DATE------------------------------ ------------------------------ Alterationsand/or recommendations:------ -----------------------------------------•---------------------•-------------- --------------------------------•---•----• -•-------- -----------------••--------------=-------------------------•-::.7.;,----------- ------------- ------------------------------•-----------------•---------------------------------------•------------------------------------ ------------- --------------------------._ ---------------------------------- ------------------------•------------------------------------------------------------------------------------ --------------...--------------------------------------------------...------- ---------------------------------- FINAL INSPECTION ------------------ ------------------- Date---- --A-!--L--- SAN -!----`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 C-59 3M 3-•63 F.F.CC.