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FOR OFFICE USE: - ', --------------- -- ----------- - ------- -- ----- -------------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ......................................................... This Permit Expires 1 Year From Date Issued Date issued ._____�-__..... .___ Application is hereby made to-thi S-an.Joaquin Local Healfh District for a permit to construct and install the work herein described This application is made in compliance with County Ordinance No. 549. a SS- --,eo—,C) J JOB ADDRESS AND O A ION._ s�_?rrt -.,------ _ --"a:_ _ 'r' �----f�-____-_- .��_- =Z --------------------- Owner's Name -------.-- Phone r � .f_ Addess.-. - ---- `t ----------------------------- _ ----±----�------------------ _ Contractor's Name------ ---------_-- = �` ------ --------------------------------------- Phone..----- ------ •------------------- Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----/_ Number of bedrooms --____ Number o aths /____ Lot size _ -� r -_____________________ ' M Water Supply: Public system ❑ Community system ❑ Privq ,De��ay1oam th tWater 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 ❑ 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------------------._____.____________.___-_-____. ❑ f` No. of compartments------ ---------------- Size----------------------------:---Liquid depth--------------------- ----Capacity------------------------ O r Disposa field: Distance from nearest well -__ ��_._Distance-from foundation____/-e?__f_____.Distance to nearest lot T Number e of filter materia- _--- Length e 9th of each line_ 1_ ..................Width of trent ----------------------------------- Type --°-�.-----------..--------.-- ��----------Total len ___-- Yp -Depth of filter material1e_ -- length _ �'-------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__._______-___-__ ❑ Number of pits----------------------Lining material-----------------------Size:'Diameter----------.------.-.-- Dept h--------------------------------6F. Cesspool: Distance from nearest well-----------------Distance from foundation--------------.----.Lining material.__-______.__..____________________- ❑ Size: Diameter--------------------------------------Depth-------------------------- --------------------- --Liquicl Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______________________________.._______--- ❑ Distance to nearest lot line------------------------------------------------ ------------------•-------- Remodeling and/or repairing.(describe):--------- • -- ---------_% -------------------------------------------------- ------- ---------------._.-------------- -- - ---------------------------•-----------------------•--- ------------------- .tk_-W-- --------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------- 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)---------------------------------------------- - ------------- ----- -------- --- -- --------------------------------------------1 r and/or Contractor) By ..............................------- ----tY �--�� --- -- -- ----�-�-- --------------(Title)------------------------------- (Piot plan, showing size of lot, location of system in.relation to wells, bindings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 0 APPLICATION ACCEPTED BY---Z_,*------ ------- ------------------------------------------------------- DATE----- ----------------------- -- _J REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------ ------------ ---- I BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE---------------------------- ----- Alterations and/or recommendations---------------------------------------------------------------------------- ----------•------------------------------------------------•------------- ---•-----•----•----------------------------------------------•------------------------------ ------------------------------- ------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------- l -------------------------------------- ............ ------------•-------•----------------•--------- .-----------.------------------------------------------------------------ -----•-------- FINAL INSPECTION BY:. ,Z. ! �t�4= / Date_- -Jf--------`------ -------------------------------------------- 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 8-59 3M 3-'63 F.P.Cq.