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FOROFFICE USE: - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete-in Duplicate) Date Issued --� -� _________________________________________________________ JThis Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit(po C ns#rust and install the work herein described. This application is made in compliance with County Ordinance I�lo. 549. « " JOB ADDRESS LOCATIO --------- ---- __/ _ _ 9� Owner's Name----- - --•• --- -- . ..c_- --- - ------------- ----- -------- ---- ---------------- Phone-•--•---------------------------•--- Address------------------ --- :- --� r---- �� --------------- ---------------------*------------------------------ Contractor's ------ ---•------- Contractor's Name----- ------ -- f ------------------------ Phone----------------------- Installation will serve: Residence [�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /___ Number of bedrooms _1_ivii Number f baths__ Lot size _____._ __ __ ------ Water Supply: Public system ❑ Community s stem ❑ De th to Water TableYp Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam El ay 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.) t p Septic ank: Distance from nearest well ________Distance//from foundation---______/Q.___-_-Mate ia L________ En No. of compartments------'Pi-----______ depth--------' ~__-----------Capacity__./-2Q._ Dispose field: Distance from nearest wefl----ar4----_Distance from foundation_____ -----------Distance to nearest IotJine__Z_... V _. _ Number of lines ------------�___-- Length of each line----- --��-____--.Width of trench-��------------------------ Type of filter material �______Depth of filter material_____0______-------Total length------7_6---------------------- See pa Pit: Distance to nearest ---Distance fro undation---/_�1_________-Dis ance�to nearest lot lin . -(r Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material _._.-_.-------------_--..___--_.____ ❑ Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. E Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F1 Distance to nearest lot line------------------------------------------------•-----------------•--------------------------------------•------------------ Remodeling and/or repairing (describe):----- y ----- --•----------------------------•--------------'----------------------- --- - ----------- --- -----'-•-------- --- •--' - --------- - ---- -----�A-- ------------- --- ----------- ---------------`--•-----------------------------------------------.. "----.. .---. ---- ------------------------------------------------------•=------------------------------------------ --------------------- 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 d rules and regulations of the San Joaquin Local Health District. Viand or Contractor (Signed)------ ---------- --- ----------• - ) Titfe----------------------- By: (Piot plan, showing size of lot, location of system in relation to Its, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-__/,40-- -------------------------------------------------------- DATE__/A� _�3 _' ___eY REVIEWEDBY-------------------------------- ------------ ------------------------------------------------------------ DATE--------------------- ----------------------- BUILDINGPERMIT ISSUED----'•------------------------------------------------------------------------------------------------ DATE---------------------------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------------•--•------------------------------------------------------------------------------------------------------•------•----•---•.......---------------------------------------- ---------- -----•------------------------------------------------------------------------------------------ ---------------------------------------------------------------------- -------------------------------------.-------------- ----------------------------------------------------------------------•-------•------------------------------------------------------------------------------------------------------------ ------------ ---- ---------------- 4 FINAL INSPECTION BY:.. p'�------------------- Date ----3--r ------------- .------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California TS 9 REVt6ED 6.59 31A 3-'63 F.P.CC.