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4�hv FOR OFFICE USE: - --------------------------------- ------------- - U _ __ _______ ___ __.................__---- ___________ _ APPLICATION FOR SANITATION PERMIT Permit No. a_ � ---- --- ---------- --------------------- (Complete-in Duplicate) -- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 544. 11,10 �.-. -- � JOB ADDRESS AND LOCATIONt tt„�_. ' ''1: J�---- - ��F� --- ' _.z ----------------------------- Owner's Name----- �je _- -•--------------•-------------- ------ - ------------------------------- Phone------------------------------------ Address.--------- ---+¢'.� - Contractor's Name----,4; -------------------•------- ------- ------------•-------------- ------- -----------------------------------------.-•--- Phone------ --------•------------------- Installation will serve: Residence'Q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1----- Number of bedrooms _ _._ Number of baths_ ~___ Lot size ----- ________________________.._._-- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table's d._ _ ft V)i Character of soil to a depth of 3 feet Sand E] Gravel E] Sandy Loam Clay Loam [] Clay El Adobe E] 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 ----_---------------------------------___..____- ❑ No. of compartments------------------- - ---Size-------------------- ------- ---Liquid depth--------- ------- ------- Capacity...--------------•---- Dispasal Field: Distance from nearest well__!�F_:D........Distance from foundation----- '0--------.Distance to nearest lot line. -- ....... Number of lines -----------I----------------------Length of each line__ ------ ........Width of trench__ ._-_______...______- Type of filter material._.AA—----------._Depth of filter material._._1_l'_'_.._...... otal length _$.�__________________________ at: Distance to nearest well... . ..._._Distance fro foundation___b_0_..........,Distance to nearest lot Iine_s,._+__-A Number of pits.-_ __I___•-----_.__--Lining material---fl-- ------- Size: etera _-I"�- ----Depth----1-err---------------------- 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 lot line ----------------- ------ --- - - - Remodelingand/or repairing (describe}-- - ----- ------ - --------------------------•-----•--------------------------------------------•-------- ----------•----------------------------------- __1-------- ---------------------------------••--------------------------•-------------------------- ------------------------------------------------ •----------•------------------------- ------------------------------------------------------------------------- ------------------------------------ ------ -------------------------------------------------------------------•---------------------------•---------•---------- --- ---------------------------------------------------- -- - -------------:----------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------ ---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State-I ws, an rules and regulations gF the San Joaquin Local Health District. Si ned•-------�e.4 - -- ------ f{ 9 � � .. � �- --- . -- ------------ ------------------------- ------------- --- �- ------(Owner 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). FOR DEPARTMENT USE ONLY ig APPLICATION ACCEPTED BY ,1C 1 -- ------ ----- - ----------------•-------- ------ DATE-/-Q------ REVIEWEDBY-------------------i-------------------------------- -------------------------------------- --------------------•-------- DATE__.-. - BUILDINGPERMIT ISSUED-------- ----------- ------------------------------------------------------------------ ------------- DATE---------------------------------- ---------- -- Alterations and/or recommendations:_------------_-------- -- ------------------------------------------------------ ------- FINAL INSPECTION BY:.. � .�t •---------------- Datefd--- ,7--- 1-._. . SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi California Manteca,California Tracy,California E.N.9 2M 1-67 Vanguard Press