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FOR OFFICE USE: - �— .•� —�- _--� 7 APPLICATION FOR SANITATION PERMIT Permit No. ------ ----------------------------------------------------------------------------------------------- (Complete in Duplicate) . ,/ w -�---�- -"----- - - - ------ - Date Issued __---- ------------ --- -----�--- This Permit Expires 1 Year From Date Issued J Application is hereby made to the San Joaquin Local Health District for a.permit to constructand install the work herein described. This application-is made in compliance with County.Ordin nce No. 549. JOB ADDRESS AND LOCATION..-W. r t Owner's Name._ ...... - Phone__ . Address________________ -----------------------•------ ------ -------------•----------------•------------•--------------•--•------•"----•--------------_---•- Contractor's Name ' Phone =._ f' --------------------------------------- Installation will serve: `Residence �5parirrent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unitsr;_ ___. Number of bedroom_ Number of baths ____ Lot size �` � fi�rr - ---- - -- -----------••------- ---- Water Supply: Public system ommunify system ❑ Private ❑ Depth to Water Table .` t. Character of soil to a depth of 3 feet: Sand El Gravel El Sandy Loam E-] ClayLoam ElClay ❑ Adobe ardpan L] Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes [] No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or of permitted if public sewer is available within 200 feet.) t tic T k: istance from nearest well__._____._----Distance from foundation______________ Material---__.____________._t___-_.________..:_ No, of compartments-------------------------S ze-------------------------------Liquid depth--------------------------Ca Capacity ty -------------- ispo ield- Distance from nea est well/_ istance from foundation. --Distance to nearest lot line__,0/0� Number of lines---- _ __ ________ _ __Length of each lire_/ :_-Width of trent Type of filter materia __. Depth of filter material_ _ �_�-_Total length--------------------- Seepage __________________Seepage Pit: Distance to neare t well_ :_ _dka- ---Distance rom oundation_._. _, Distance to nearest lot li ..� s _.. Number of pits._7................Lini material._ ------Size- Diameter_ -rr ��pepth - Cesspool: Distance from nearest well-----------------Distance :_�m unclation--------- _-----------Lining material-------------------------------- __ S ❑ Size: Diameter--------------------------- ----------Depth--""- -- ------------------------------- s Liquid Capacity - gals. Privy: Distance from nearest well____________________ ----------Distance from nearest building Distance to nearest lot Zine___ ____________ ------ _____________..._ Remodeling and/or repairing (describe):_,_ __._ _-. _ ----------------------------------------- --------------------------- ------------------------------•--- --•---- -------------•---- ••---- -------- -----•---------------- - ----- = - to ----" "- -------------------------------------------------------------------- I I hereby certify that I ha a prepare th s application and th the work will be do in accordance with San Joaquin County 7 ordinances, Sta aws, rules and uI ians of the Sa Jo uin L l Heal- ordinances, Dist ict. (Signed)----- ---- ------ -- -�7. - - -- -- - ---------- - --- - -------tf n Contractor) BY:-------------------------------------------------------------------- (Title) N --------- - - ----- ------------- (Plot plan, showing size of lot, location of system in relation to s, buildings, et ., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By---- DATE__-.___- ____ � _._ 5 -_---------- REVIEWED BY------------------------------------- ------ "----------------------------------------------- DATE--------------- --------------- -•------ UILDING PERMIT ISSUED----------------------------------------------------------------Z-------------------------------------- DATE-------------- terations and/or recommendations_________________________ h ------------------------------ ---------------------- ------------ FINAL INSPECTION BY:-.- --------- ---G __--- Date----------- - �.- -------------------------- AN JOAQUIN LOCAL HEALTH DISTRICT i 1801 E,lNoxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Scree! Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 19-69 3M 3-•63 F.P.CO.