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FOR OFFICE USE: ---------------------- __ _ _ APPLICATION FOR SANITATION PERMIT Permit No. -- ---------------------_,--__ --_. --------------------- _ -(Complete in Duplicate) Date Issued .-__------ ----------------------------------_.__. This Permit Expires 1 Year From Date Issued ©.Ss- 30 -® � Application is hereby made to the San Joaquin Local Health District for a permit to constructand install the work herein escrib�d. This application is made incomplia - with Cou ty Ordinance No. 549. �f to . b JOB ADDRESS AND LOCATlO ,�- - Z �'� Phone ---- _ Owner's Name-------- ! °Z ---a-- ------------- .. � -----' ------- ••----------ss - ------ - 1Addre - --------- Install r t Phone..................... Contractors Name-- � Installation 1 will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms J--- Number f baths -� Lot size ------- ---- - I Water Supply: Public system ❑ community system ❑ Private Depth to Water Table -------- ft. Character of soil.to a depth'of 3 feet: `Sand❑ GrdVel❑`"'Sandy-Loam{0- 'Clay.Loam_❑ Clay.�obe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No,❑ New Construction:-Yes ElNo ElFHA/VA: Yes E] No ❑` TYPE OF INSTALLATION AND SPECIFICATIONS: [Na septic tank or cesspool pertnitted�if pablic sewer is available within 200 feet.} Septic ank: Distance from nearest welIS-6—n__Distan from foundation_____�_�______':Mat rial______.._-If________ _______________ ___ 52l No. of compartments-----_-____--------------Size.. `X_ box _''� Liquid d pth------'- ---- -----------Capacity--le�!-4i` FG _____________Distance to nearest lot line-_�_-.__..!r_ Dispos geld: 'Distance from nearest well ___ __.Distance from foundation____ r _4.. Ze ------------..If Width of trench. r' t Number of lines---------:= ^-------'-, Length of each line-------- ---- �P Type.of filter mateeial__ ._Cepfih of filter material -_____________Total length________I-lu_ _.-_____________.-_--' Seepage Pita Distance to nearest well___-------------------Distance from foundation--------------------Distance to nearest lot line_____-}_.______- E] Number of pits-4___�---------------Lining material--------------------- Size: Diameter----.-----------------.Depth....------------- ---------- -- �' y Y .1 I 6- �C'esspool: k Distance from nearest well----------------- from foundation----_--------------__Lining material-_____. .._____--____. ___.__-____:� -�' ______Liquid Capacity I \❑ Slze� Diameter- 1----=------------- --------------Depth------ ------------- -----------'----- - 9 p y----------�------'---- Privy: Dislance from Jearest well________----------------------------------------Distance from nearest building ---------------- _ Distanceto nealrest+lot line--------- ------------------------------------- ---------------------------------------------------------------------------- = 5 i _wa`r.._c�.i.1. Remodeling and%or repairing (describe)=--------------- ---- --------------------------••----------------------------------------------------------------------------------------- ------•------ _________---_-------- __F__-___.___________.t----------.-___-____-_______._-- -_____ __ _____-________._____-_______________--_________________ .-___.. -----------------------_-------------------_---------------------------------------------------- I1 _________________________________ ------------------------ -------------------- ______________,_____-_-____________--______---_____.________________...---__._____________.-.-______..____________________________________- . I hereby certify that I have prepared this application and that the work,will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. \ -- (Signed)---- -------------- ----- ----- ---------------- - ------- -----------' ' --' /or Contractor) BY:------ ---- - e)--------------------------------------------(Title)-------------------------------- --------- -------------- (Plot plan, showing size of lot, location of system'in rel` ion to.wells;buildings,-etc.; can-be-placed-on-reverse side).-, -_ k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY_ ---- ------------------------------------------------ DATE = -- ' ' ' REVIEWEDBY------------------------------ ------------------- -------------------- ------- -------------------------------------- DATE----------------- ---------------------------k---=---------- BUILDINGPERMIT ISSUED-------•---:i---------------•-------- ------------------------------•------------------------ ---- DATE-----------------------------------------------=------------- Alterationsand/or recommendations----------------------'----------- ---------------------------•---------- ---------------------------•------------•-------------------=---------------------- i i ---• ---------------------- ----------------------------------- ----------------------------------------•-------- ------------ -- ---------- )I -----------------_______._---._____---..___.-.-----_. F t r_/ 1l FINAL INSPECTION BY:. � iA -------•--------------- Date-- ------------------- ' ' - ' r I 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 4 REVISED 6-54 3M 3-'63 F.RCC.