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FOR OFFICE USE: ------- -- APPLICATION FOR SANITATION PERMIT Permit No. t li D l ------------------- ----------------------- ------------ (Compete in Duplicate) / f Date Issued _._. ----------_------ --------------------- This Permit Expires 1 Year From Date Issued 1 Application is hereby made to the San Joaquin Local Heal+h District for a permit to c nstruct afid in all+he work oreip described. This application is made in compliant w• h County Ordinance 549. �'�k �� -4 Of JOB ADDRESS AND OCATION....I., " '� .I ... L --•- Owner's Name. _Phone. - = - - , g AdAress----- ---------------- C. i '�' - •-------- Contractor s Name---- v Phone.. ------- n t, n will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Q Motel ❑ Other ❑" Number of living units: ._,__- Number of bedrooms .,I- Number of baths ...f. Lot size ________________ _ _________ Water �pply: Public system [3 Community system ❑ Private Depth to Water Table Charasr of soil to a depth of 3 feet: Sand ❑ Gravel [:] Sandy Loam Clay Loam 0 :Clay ❑'..:Adobe❑: Hardpan ❑ Previous Application Made: (If yes date____________________ No ❑.. New Construction: Yes E] No E] FHA/VA: Yes ❑ 'No El ; t TYPE OF�,INSTALLATION AND,SPECIFICATIONS: ( 1 d septic tank or cesspool permuted if public sewer is available within 200 feet.) N < 9 Material Tank: Distance from nearest well_________________Distance from foundation______._....____._.Material.._----_______--_______---------------..___-.._.. No. of compartments--------••------- ---•--Size------- Liquid depth ; -------Capacity-•---------------e--- ❑ 1 ' I Disposal _field: Distance from nearest well-------- from foundation....., . ___Distance to nearlbsst lot lit e..�._....... E Number of lines'[ ... Length of each line----------- _f ...-_; Width of trench...st �_________________ i +• Type of filter material._._ ---Depth of filter material------/_-____ ._.Total length_,_._.:___ ___________________ , Seepage Pit: Distance to nearest. well-----------Linin material from foundation Diameter�. Distance +o Dnee��st lot line_________________ '.i ❑ Number of pits-- ----------- • g "..... Cesspool: Distance from nearest well-----------------Distance from foundation___.__________..._..Lining material_: ------;------------_..-----_. Size: Diameter_-----------------------------------Depth----•---------------------------•----------- ❑ Liquid Capacity _ .-_....... : :-:gals. Privy: Distance from nearest well.... from nearest building_ ._ ;_...__.________._...______.. i ❑ Distance to neares} lot line ---------�--- ----------------------------------------- « M �- i. f. �1 I , ------ - �... 0 1 - -• - ---------........ _•--------- . or repairing (describe):--------- 41-------- ---- _ ..----___-- _-_ „ �•-••-� } ➢ _____________________ :_.__-.-____...-________-_-_-•_-_______-._______----_________._-____._......_.____......._____...._________._-......__ ___. ..____..._....._..____..._..-_____________._._.__-_____--_ { ___________________________________________________________________________________________________________________________________________________________I..___ v� I .. ------------------- ------ -- , -------------,----------------•-------------•-•-------------------------- • ; I hereby certify that.),have prepared this application and that the work will be done in accordance with San Joaquin County { ordinances, Stat laws, andlrules anre ulations of the San Joaquin Local Health District.? i Si ned ( 9 1 M - ---- _ --------- _' � _. -- fir Contract �(:r -------- y;.....----- •- -•- . ---- --- (Plot plan, showings size off lot. locatio of system in relation 4to Its, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY I ' APPLICATION ACCEPTED BY.:_-': ---------------- DATE.------- ------------------------------------------------•._....------------ e-------- REVIEWED BY---------------•-- ------------- -------- -------------------------- DATE' -------------- ......... BUILDINGPERMIT ISSUED------_- ----------------4 _--------------------...-----------------......---------- DATE._!---_------------------------- ----------- ----....... ..................... ...... --------------------------------------------------------- Alterations and/or recommendations:__3�'`________________`.__.__----------.-----_--••- -- dI....-------------------------......................----------- } --------------------------------------------------- ; ------------------------------------------=------------- ., ` -------------------- =•----------... -------------------------------------- --------------------------------- --------------------- ------ - ------------- ------------------ ------------------- --------------------------•------------- ----- t. FINAL INSP1 C710N BY:. .N Date----... ._�� _.�. .. SAN JOAQUIN LOCAL HEALTH'D15TRICT t 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California / E5 9 REVISED B-59 ZM 8-61 ATLAS