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FOR OFFICE USE: y _______________ ______________________________________- '"' �•� ----- ---------------- -------------------------- APPLICATION FOP, SANITATION PERMIT j�.y� Permit No. .. {Complete in Duplicate) �� f f� � . - �' bate Issued ------ ___-� ---�� ---------------------- This Permit Expires 1 Year From 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. 549. 4. JOB ADDRESS AND LO TION----� '-`�- -- ---- --------- ---------------------------------------- Phone ------•- d �� ^...._ •� Phone--- -------------•-------•---- Owner's Name- - -- AddressC L `� '°f-------------- ---------..---------------------•------------------------------------•----------- Contrector`s Name-------------- ...--- Phone----••----_------•-----•-•----- Installation will serve:&9,Residences Apartment House ❑ Commercial ❑ Traile Court ❑ Motel ❑ Other ❑ Number of bedrooms .- Number of bath �Lot size ____�_ _ -- -t -.��--- ----------------- Number of living units:,__ " Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .-�._ _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan C1 Previous Application Made: {1f yes,date.-------............) No PT New Construction: Yes - No ❑ FHA/VA: Yes ❑ Not TYPE OF INSTALLATION AND SPECIFICATIONS: F �� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �-- Septic-_Tank: =� --�'-Distance","from-nearest-"well-_LL_�-�_=Dista e�FfromTfoundation—_f�___=:�-Mater�l�:-- .._ . ._- ----------- _____ _ ______ No, of compartments_..s�_------------------Si�`_ -x-J! X..67--Liquid depth__._.-'�7t._ ! Ca"panty../ �------ /" n Dispo al Field: Distance from nearest well__A_e't"Distance from foun�latip�n.,.:_1p---------Distance to nearest [of�np------ _____.__. Number of lines --------------------------------Length of each lin � ,r-- -------- Width of trench------ -- .y Type.of.fiiter material_S� T-4C-----Depth of.filter materEal__/�i_____.-____.dotal length__. Q __________ ______________ 9 41 Seepage Pit: Distance to nearest we1L____________________Distance from foundation--------------------Distance to nearest lot line------- ❑ Number of pits---- -----------------Lining material----------"------------Size: Diameter---------------------- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ mate ria l- ---..._____---_--_.___---_-______ _- hLiquid Capacity - 9asSize: Diameter-----(------------------------------ Dept ------------------- ---------- uildi Privy, Distance from nearest.well-________ ______ _____ --------------- - istance from nearest - ❑ Distance to nearest line ------------- ---------------------------------- •------------------------ _ Remodeling and/of repairing describe :____-_-_ .___ .. ___ __-�t�c-��' �'-- ------------------- ---------' .' ----------------------------- - it i ---------------------------------- - -------.. ----------------------------------------------------------------------- ---------- •--- _ :_. I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and eguia 'ons of the San Joaquin Local Health District. ----------------------------------------------- /' {Owner and/or Contractor) -------------------------------------•--------------------(Tit .(Plot plan., showing_size:of lot,_lacetion„of� ystemTtrr�relat..ionto-weNs„buildings,retc.,canbetplaced,on.,.reverse._side).-�� •- =-_�':.:.= --� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -- ----------------- -----------•-=---------------------.----.DATE---------------------- --------------------------- ----------- REVIEWED BY-------------------------- --------- ----- - "------------- ---------------------------------------------------------------- DATE----------------------- ---------- PERMIT ISSUED--------------- - - ------ - DATE-----------— - --��----`�----- --------- ------------ --------- ------- --------- Alterations and/or recommendations:--------------------- ---•--------------------- -----------------•--••--------------------•--••--•--•---------------------------- -- --- ----- - -- - €: ----------•------ -----------•------------------------------------------------------- I -----------------'------------------------------------------------ ----------------------------------- FINAL INSPECTION BY-------- ------- --- — Date...... `^ f/ ----------------------------- ------ d `- SA JOAQUIN LOCAL HEALTH DISTRICT 1611. ielton Are. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED S-S9 3M 3-'63 r,P.RO. v 1 .r'.