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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------------- ' (Complete in Duplicate) _ Date Issued ------------------------ --- -------------------------- �"'„ ThisPer - From Date Issued mit_Expires 1 Year Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. rr. This application is made in compliance with County Ordinance No. 549. ©Ce(-(L((7. 57 ' JOB ADDRESS AND OC TIO ......----------`--C .�- .--``-/ -.-�' v--=`-''-"'-------- ' -------------•---- Owner's Name t , ., ------ - Phone -..::. -- Address. l ---�---- a ---------------------------------------- Contractor's Name------- ----• -- - ---------------- Phone , Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer"Cour} ❑ Motel ❑ Other ❑ Number of living units: ---/___ Number of bed rooms,=_.N_mber of baths _-_ Lot size -------- --_---_.-_ + —WaterSupplyPublic system ❑'mC mmunity syst m❑ 'Private Depth t Water Table --------nft. y Tw Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ k Previous'Application Made: (If yes,date-_-----------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ a TYPE OF INSTALLATION AND SPECIFICATIONS: h O (No septic tank.-or--cesspool-permitted if public sewer is available within 204 feet.) Septic Tank: Distance from.near st•-.well_---_--_-_.----Distance from foundation--------------------Material _----_-_--,.---------.--_----E----------------- . ❑ No. of compartments---- ---`--F _ Size----------------------- Liquid depth-- Capacity T Disposa field: Distance:frgm:nearest well------SO__._,Distance from foundation-----/' ---------Distance to nearest lot - line --------------- Number of lines------------ _ g#hfach line---------/UQ----_- ----Width of trench.----,�` ,__------- -- --------- ;Typeoffil.#er„material---r- -----Depth of. Iter' ----_.% m ---- Total length----------I-AP--------------------- 'b P Seepage Pit: Distance to nearest well____- �___.__.___,Dsstance from foundation____________________Distance to nearest lot line.____.__........ of Its---------- -----------Linin material---...\. __--.____Size: Diameter------..__.__..._-_ - .. I..----------------------- Number❑ P g Depth------- ¢ Cesspool: Distance from nearest well-----------------Distance from.fbundation------------._ g -----.Linin material-----------`----=------------------- ryr❑ h Size: Diameter--------------------------- - ----- -Depth-------------}---------------------.-----------------Liquid Capacity---------------------------gals, Privy: i Distance from nearest well-----------------------------------_---.:._.._Distance from nearest b0cling------------------------------------- - '>r ❑,j Distance to nearest lot line-------- ------------- -----------------r t ----------------------------------------------------------------------------------------------� V � � I � O Remodeling and/or repairing (describe):_ ........ -------------------I--------------------------- ---------------------------------- ( , r -ty------- -----------------------------------•-`-•• 4---------------•----------------------•------------------------------------------------------ f { f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County!' ordinances, Stat laws, and rules and"regulat' of the San Joaquin oval Health District. (Signed).----- '` -=-- ' t ..and/or Contractor) BY•------- --------- ------ =-0 . _-- T _ �- Title) ___: _ (Plot plan, showing size of lot, location of system in relatio fo wells, buildings, etc., can be placed on reverse side). r ' FOR DEPARTMENT USE ONLY APPLICATION.ACCEPTED BY- ----------- --------------------------- ------- . --------------- REVIEWEDBY------------------------------------------------------------------------------------- ---------------------------------------- DATE------------------------------------------------------- BUILDINGPERMIT ISSUED_------------------------------------------------------------------------------------------------ DATE------------------------------------- --------------- Alterations --------------------- •--- Alterations and/or recommendations:----------------------- M ---------------------------------- •-----------------------•------------------------------------------------------------ --------------------------------------------- ----------------------------------------------------- FINAL INSPECTION BY:- -- -----•-- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California ' Lodi,California Manteca,California Tracy,California , CS 9 REVISED 8=59 3M 3-'63 F.P.CD.