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FOR OFFICE PSI;: -- ------- ---- -- - �. f 3/f ____ _ APPLICATION FOR SANITATION PERMIT Permit No. ............ --------------------- ------- ---------------------------- (Complete in Duplicate) 3 Date Issued .____ ------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made'.t; 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 o. 549. JOB ADDRESS AND LOCATION..... _3_ _ _ Owner's Name__. - - --•--•-•--------------------- -----•-•---------------•------------------------------------------ ----'Phone--------------•-------------------- Address --- ---<- `3-'!'1'e --'- Contractor's -- /,... = Contractor's Name----------- -------. ... �---- --------------------•------------------------------------ Phone.............. •--•--------------- Installation will serve: Residence [P- Apartment House ❑ Commercial ❑ -Trailer Court .❑ Motel ❑ Other ❑ Number of living units: _1__- Number of bedrooms _,3___ Number of baths _-__- Lot size --- Ox----/J45.`--------_______________________ Water Supply: Public system 0- Community system ❑ Private ❑ Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy L as Kb Clay Loam ❑ Clay ❑ Adobe(A--Hardpan ❑ Previous Application Made: (If yes,date-------- ---------.-) No E' New Construction: Yes [e-No ❑ FHA/VA: Yes ❑ No P-- TYPE OF INSTALLATION AND SPECIFICATIONS: j. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SeDistance from nearest well________________Distance from foundation--------------------Material--------------------------------------- Z� _.No. of compartments--------------------- ----Size-------------------------------Liquid depth---------------------------Capacity...___.________._.._.. Disp sal E Distance from nearest well-------------..._.Distance from foundation.......-------------Distance to nearest lot line•_______.___...-. (� Number of lines-----------------------------------Len gth,of.each"I ine____ '_____--_._....-___.Width of trench._--_._._____________..______ Type of filter material----_--------------------Depth of filter material_______-_______________Total length-------------------- ---------------- Seepage Pit: Distance to nearest _______Distan rom foundation-44!-----------D•sstance to nearest lot line_$77�_.._-_.. Number of pits----- �____.___.__Lining material al____ _ _ �____r.5ize: Dameter-______�___ ._ ---Depth----- Z5--•---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____.--.________________________.___.. ❑ Size: Diameter----------I---------------�--------.Dept h-------------- - --------------------------------Liquid Capacity - gals. I �-------/__ ___----�Distance from nearest building Privy: Distance from nearest well---- --------------=- -!i_ 9 ❑ µ � Distance to nearest lot Iine_=i-----------------------till" -------- ' __ r �o.ff ------------------•---•----------••--r-- iRemodeling and/or rearin Iderib ---------- - _ -----------------•--------------- --------•---.. v -- ._. Gt -•-- -----------------••---------- --------t4,.I——---------•------------•------------------•-----------------•------•-------------------------- -------- ------------------------------------------------------------••----••---------------------------------- I hereby certify that I have pr ared this'applicafion'endYthat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules a r ulation of the San Joaquin Local Health District. [Signed}---------------------------------- --- -------- --- -------------------- t (Owner and/or Contractor) BY:-------------------- --------- -- ---- ------------------------------------ [rile} } (Plot plat;, showing Size of lot, to ion of system in relation to wells, buildings, etc., can be placed on reverse side). -k - n FOR DEPARTMENT USE ONLY APPLICATION�ACCEPTED_BY.__,._ ,__�:- '�-.�:- k---------------------- DATE---..:�>_ • ` .f---------------- REVIEWEDBY---- -------------------------------------------- ------------------------------- " ---------- ------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------" ----------------------------------------- DATE. ------------------- Alterations and/or recommendations:------------------------------------ "" ------------------------ --- t ---- ----- ------ - f ------------------------------------------------------------ ------------------- ------- -•---- -----------------------------------------------_...------------------------------------------------------ FINAL INSPECTION BY: - r � Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street , A 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9.9 REVISED B-59 F.P.C13.2M 6.613 '',y