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FOR OFFICE USE: 4r,4 1�/4j 17 17 2__ -3 ----------- ------------------ APPLICATION FOR SANITATION PERMIT Permit No. - -- -- ---- -- _ _ ` ----------------- --------- `t ------------ (Complete in Duplicate) S 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. JOB ADDRESS AND LOCATION-•_�_21_._ _ ._ -- 5 Owner's Name ------A - ----- Phone------------------------------------ Address.,...-Contractor's Name--C ----------------- ..•_--------------------------------- ----------- Phone.------------------------•------ - Installation will serve: Residence [Apartment House,❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __1___. Number of bedrooms I. Number of baths ---I---- Lot size '_47----x- - _ +_ _____________ Water Supply: Public.system ❑ Community system ❑ Private ❑ :Depth to Water Table -ib6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Ilf yes,date------_--------___.1 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 feet.) Septi art - Distance from nearest well------------ -Distance from foundation--------------------Material---------------.------ -----____----_--.___.-___. No. of compartments--------------------------Size--------------------------------Liquid depth------------ - - - -------Capacity----------------------- Disp ?Fi Distance from nearest well-�6 1.._..-Distance from foundation----J_f7-----------Distance to nearest lot line-- -------_---- � r Number of lines_._..--�-----I-�--------- ---------Length of each line---- - -----,�---__--.--Width of trench- -- --�----__-------:----____-- Type of filter material____!v_(.t---____--Depth of filter material-11...............Total length-----�_4 I Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line-----._.___-.__.. ❑ Number of pits___-__i--------------Lining material------------------_x---Size:,Diameter----------,------.......Depth-----------------.--------------- evCesspool: Distance from nearest well____.--_--_--.-_Distance from foundation___________________Lining material__-_.-_-------..._.-_.__--.---_-_.__. ❑,. Size: Diameter------- ------------------ ----- ----Depth----------------------------------,-----------------Liquid Capacity----------------------------gals. Privy Distance from nearest well-------------------------------------------------Distance from nearest buildir)g------------------------------------------ ElDistance to nearest lot line------------------------------------------------------------------------------ --------------------------------------------------------------- Remodeling and/or repairing (describe):--------- -------- ----- -------------------------------------------- ---•----------------------------- --------------------------------------------- --------------•---.........-------------------------------------------------------------------------------------------------------------------------- •---------------------------- ---------------------------------------------••-------•--------------------._...------------------.._---•------------------------------------- ----- -----------------------------------•------------------------------- -------------------------------------------------------------•----•-------------------------------------------------------------------------- -------------------------------------------------------------------------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, annrdd rules and regulations of the San Joaquin Local Health District. (Signed) ^--A- :1~ p� -----------------------------------------------------------------------------------------------(Owner and/or Contractorl $y:--------•------_--�C_ � = F [Title) - --------- - ---- - - -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY # APPLICATION ACCEPTED BY-------- ---------- `- ------------------------ ------------ DATE-------- ` REVIEWEDBY--------------------------------------------- ------------------------------------- DATE----------------------- -------------------- BUILDING PERMIT ISSUED------------- ------------------------------------------------- -5---- DATE Alterationsand/or recommendations.------------------------------------------ -- ---- ------------------------------------------•------------------•------------------------------------ 4 _.__._--__.-.-________________________________________________________________________________________________________________________________________________________________________________________________________________ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------_.---- ----- FINAL INSPECTION BY:____.....-._ _ pate__.____�1 .� - -- -------- - ------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 340 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California es 9 REVISED 8-S9 3M 3-•63 F.F.CD.