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FOR-OFFICE USE: 4.6.. ----------------------- ----------------------------------- APPLICATION FOR SANITATION PERMIT Permit.No. .............. ------: (Complete in-Duplicate) Date Issued Al-�- ------------ --------------------------------------- 0" - I This Permit Expires I Year From Date Issued ----------- ------- ----- -------------------- -------- Application is hereby made to the San 1Joaquin 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 AUD,,LOCATIO ---- --- Phone—-------------------40•------ ----------------- Owner'�,'Name------------------ ---- - -- ---------- -- ! --- ----- - --------------- --------- ---- ----------- ----------------------- ------ ------- - ----------- Address---- I------------------------- - one--------------------------------- Contractor's Name----------- -------- Ph Install'ition will serve: Residence F1 Apartment House F1 Commercial el*`Trailer Court ❑ Motel El Other ❑ ---------------------------------- --- ------ Number of living units:-7---- Number of bedrooms= Number o-f baths 4Lot size ----------------- Wafer Supply- Public system ommunity system 0 Private L] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand El Gravel 0 Sandy Loa!m 21--�Clay Loam El Clay E] Adobe 0 Hardpan C] Previous Application Made: (if yes,date-----------:--------I No-171 New Construction: Yes El No E] FHA/VA-. Yes El No[I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool-permiffed,-if public-sewer-is�avail6blewithin 200 feet.) e Of Septic/Tank: Distance from nearest well---4P?_-----Distance from four)dafiop--------------------Material----- - -------Size--- No. of compartments___"._2-------- Liquid depth------- ----------Capacity Distance from nearest well.--.-7'0 -f.-Distance from foundation-- 0--.0------Distance to nearest lot lin --------------- DisposalField: Number of ines--------/-------- ----Length of each line-----/-0 ----------Width of french----- ---------- Type of filter material----��--Depth of filter. material---tV----y------------Total length-------40-0--?------I----------- ance from foundation-------------......Distance to nearest lot line_________________ Seepage Pit: Distance to nearest well_.__~ ----------'-Dist ❑ Number of pits-\___5_"_'L----k-„--L'ininmaterial__------------------ r -Size: Diameter---------------------Dep6- -------------- -------- Cesspool: Distance from nearest well-----------------Distance from foundation----- ___________.Lining material-_..____-____.-,_.__._______ _ ------------------------------- ------Liquid Capacity--------- ..-. apacity---------------------------gals C.0001 ❑ Size: Diameter------ -- ------------------ Privy: Distance from nearest well------ ---i......Depth------------- Distance,frorn nearest building------------------------------------------ ---- ----------- ------------ 0 Distance to nearest- lot line-------- --- ---------r---------------------------------------------------------------------------------------------------------------------- - ------------------------- ------------------------ Remodeling and/or repairing (describe):-- --------------=--------------------------------------------------------------------------- ----------------------------------------------------------------------------------- ---------------------------- -------------------------------------------------------- --------------- - ------------------------------- -------------------------------------------------------------------------- ------------------------------------------------------------m-------------------------------------------------- ---------------- ------- -- --------- as -------------- -------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ n I hereby certify that 41ha prepared this application and that the work will be done in accordance with San Joaquin County"a, I ha a ordinances. State laws, an ru and regulations oft bjSan Joaquin Local Health District. -----------------.-.t@WK5F:-and/or Contractor) (Sigred)------------------------ --- ------- ----- ---- - ------------------- ---------------------- ------------- -----------------------(Title)------------------------------ --------- --- --------- ----- By:---------------- --- ----- ------- -- ------ ...... .. -------- (Plot plan, showing size of lot, location of system rection. , well buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------------------ 41r-DATE--j-7 -74 -------------- ----------------- -- - - -- ----- ----------------------------- REVIEWEDBY------------------------------------ -- - ------ DATE------------------------------:---------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------_----------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---------------- --------------------- ---------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ----------- ---------------- ---------------------- ------------------I--------I---------- -------------I----------- ----------------------------------------------------------------------------------------------------- ----------------- -------------- ------------------------------ m. ------------------------------------- .---- ------ --------------------------:---------------------------n---------------------------- -------------------------- ------------------ ----------------- ------------------ ----------------------------------- ---------- -----------------------------------------------I------------------------------------ --• -- � -----•---------------------I------------------- FINAL INSPECTION BY:----- . .. . ------------ Date--:�-'Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 360 West Oak Street 124 Sycamore Street 205 West 9th Stre." Stockton,California Lodi,California Manteca,California Tracy,California rf CS 9 REVISED 8-59 3M 3-'63 F-RCEI- __2