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FOR OFFICE USE: --------------------------------------------------------- / ..--------------- --- -- ------------- APPLICATION FOR SANITATION PERMIT Permit No. .__I"".. ----------------------- --- --------------------- -------- (Complete in Duplicate) Date Issued ---------------------------------------------- ----------- This Permit Expires S Year From Date Issued Q.SI- 2 5�-SS' Application is hereby made to the San Joaquin Local Health District for a permit to constr..uct..and install -the work herein described. + This application is made in compliant ith County Ordinance No. 549. � U ,�6,0 f 1 �. . --------------------- JOB ADDRESS AND 1 ATION.... �I �-c L( .r` `� - - = Te --------.------------- Owner's Name �! -1 •---•-•-------------- -- --------------------------- Phone �. -------- -------- -------------- --------------------------- 40 ---------------- - I---- _7----4 -------------------- -------------------------------- Contractor's Name------------------------------ ------------ ---------•- -------------------------------------•-•--------------- •--------------- Phone------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ - Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms ---I--- Number of baths __J--- Lot size ______________ r ------- Water Supply: Public system ❑ Community system ❑ Private EeDepth,to Water,.T.able ________ 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--------------------I 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.) Septic Tank: � Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------------.----------- No. of compartments--------------------- ----Size---------------•----------------Liquid depth------------------` Capacity (> e Dispasa field: Distance from nearest well.... "4_-__Distance from foundation.------/--P__.._.Distance to nearest lot...ine__. _-..._.. dr Number of lines------------11._....___.__-___-_Length of each-line---:___1:��-_-___ Width of trench--.2___________ 4 Type of filter material____.- _ _____-Depth of-filter material------- length_---__-_`_p_�____________________ -,See pa Pit: . Distance to nearest well_____16O-----:Distance from {4undation_-_--�0-----_-_ Distance to nearest lot line--w5' / ,{j rz !, j ---- Number of Its-------- -------_----Linin material__—jd _ -��- -- --Size: Diameter------- .._3-- _--Depth_..._. -„�-------------• Cesspool: Distance from nearest well---_-__--g-�-'-Distance'from foundat.ion____________________Lining material-----------_________.____.________ ❑ Size: Diameter--------------------------- ---------Depth-------------- ------------------- - ------------.._Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------'------------------------------------Distance from nearest building_____-..__________-______________..___.._ :. ❑ Distance to nearest lot line--------------------------------- - --------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)=------- --•--•---•-------------------- •--------------------------------------------- -------------•---------------------------------------- ----------------------------------------------- E ------------------------•-------------- ---------------- --- ------------------------••----------------------------------------•-•------------------------------ Z i V I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin County 'h ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. Dof 4 OG (Signed)------------------------ @i -end/ar Cantrac+ar] gY= :;:_3 - [Title) r (Piot plan, showing size of lot, location of system in relation to wells, ildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATlON.,ACCEPTED [iY ---------------------------------------------------- DATE-_ ?` riS` f� of - ------------------ REVIEWED BY------------ `------------------------------------------------------------------------------------------------------------------ DATE------------------------- --------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------._ DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------ -- - - ------------------------------------------------------------------------------------------..------------------------------------- ' ---------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ----------------------------------•--------------------------------------------------------------------------------- ----------------------------------------------------- --•---•----------- --------- ---------------------------- -------- --------------------------- -------------------- ------------------------ - r----•-------------------------------------------------------------------.----�-------- --------------------------------------------------------------- FINAL INSPECTION BY:..41 - - ------------------------------- Date-- 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 ES 9 REVISED B-59 3M 3-'63 F.F.CO.