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FOR OFFICE USE: ------------ ------ -------------------------- ------- - APPLICATION FOR SANITATION PERMIT Permit No. lyr;.�._ -------------------------- --------------------------- (Complete Duplicate) Com lets in D From Date Issued Date Issued - ---------------------------------7--------- - It .. __ This Permit Expires 1 Year ,,�� Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work e eine Je i�ed.Z This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND. OlON-- --- ----- -------------'G ---------- --V- --' '--C ---------- ------ �- Owner's Nam ---- -.----- ----------------- Phone - i� Address. -,-�--- ----- -- ------------------------------------------------------------- Contractor's Name = �^'r Phone --------------- Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] Motel ❑ Other ❑ / 22 r_ Number of living units: _/..____ Number of bedrooms _rte._ Number of baths ___t___ Lot size --------------3A&--- - -�� ----____--______ Water Supply: Public system ❑ Community system ❑ Private eDepth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-------.------------) 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 ' ithin100 feet.) Septic ank: Distance from nearest well-___-r.-'._�-----Distance from f ou nd`tisn__.__,`+?_ _._.Material___. ------ ________�Z ------ No. of compartments__ - Size _�____ _ __.1� _Liquid depth_____r _�-------------Capacity----i4i, Dispos field: Distance from nearest well. Distance from founda-fion__j_V-------Distance to nearest lot)ine----�f._____ Number of lines------------ /__._ll__�_ j1 Length of each line_______- -_____-_--_-.-_.Width of trench.`„ -�_________________________ Type of filter material-_„ASI-C-1-------Depth of filter material___ --!_9-- ---Total length---__--P------------------------------ e Distance to nearest well-----/Pa__1----Distance from foundation____1h---------:Distance to nearest lot lint'-----`$ ❑ Number of•prhs: -__�---Lining material_-___ - ----Size: �r._ __x_ �-_Depth_..____`y_______ Cesspool: Distance from nearest well------- ______'Distance from foundation-----.;.----------.Lining material------------__._______._______-____-- ❑ Size: Diameter----------------------------- ---- ---Depth------- ---------- -- ---------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___--------------------------------------------__Distance from nearest building_____________.___________-___________._. ❑ Distance to nearest ]of line------------------------- ---- ------------------------ -----------1'17_-_____--'----- ------------------------------ Remodeling and/or repairing (describe):-------- --------------------- -------------------------------------------------------------------------------•---------------------------------------------------------------•--------•-------------------------------------------------------------------- - -----------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------- -- - - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---- ---- �.t, ; =-------- --------------- and/or Contractor] ----------------------------- By:--------_------- -- -�----------`- ----Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). / A, FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY- 1 -- ------------------------------------------- DATE --------------------------- REVIEWEDBY--------------=---------------------------------------- ---------------------------------------------------------- DATE------------ ----------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------=--------------------- DATE--------- ----------------------------------------------- --- Alterations and/or recommendations:. - r----------- -------•-•-------•----------------- -------------- ------------------------- --------------------- ------------------------------------------------------------------------------------------------------------------------ --------------------------------------------- -----•------------------------------------------------------------------------- --------------------- - ------ ------------------------------•---------------------------------------------------------------- --------------------------------------------------------------------- -----.- --- -------------- > ------------------------------------'---- ------------------------------ Zf FINAL INSPECTION BY:._ _...-------` "� t `- --- -------------------------------- I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.'Hazeltan Ave. 300 West Oak Street 1:2�flSycamore Street 205 West 9th Street Stockton,California Lodi,California ?.lVicnfeca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.DD. •-iaitYc�i.iri .. }