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FOR OFFICE USE: • 4 1:30 APPLICATION FOR SANITATION .PERMIT Permit No. ....--.....-;_.....- ( I Pate in D (Complete Duplicate) S w P� -____-;--�------- ---------------------- This Permit Expires 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 . 549. JOB ADDRESS AND LOCATIO - ----------_---------------------- ----------------••--------- ---------•----- ------------------------------------•--------------------------------- f Owner's Name Phone------------------------------------ -------- -- Address----------------- ------------ - ----.. ...---- -- ------------------ •-------------------•-•-----------------•-•-------------------•------------------------------------------------------ Contractors Name--------- -----------------------------------------.-------------------------•--------------------•---------------------------- Phone----------------•- ------ Installation will serve: Residence Q��Apartment House ❑ Commercial ❑ Trailer Court E] Motel E] Other Elcs�Cbc10- Number of living units: ___�__ Number of bedrooms .---�Number of baths.-_ Lot size ___ ____ _ -------- ------------------•------- Water Supply: Public system gf/ommunity system ❑ Private ❑ Depth to Water Table -_ Ot. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date-------- ----------) No New Construction: Yes'❑ No Wj-""FHA/VA: Yes ❑ No [` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septick or cesspool permitted if public sewer is available within 200 feet.) Septi k: istance from nearest well-----------------Distance from foundation__________________.Materiai----.____._____._------_____________._______- o. of compartments--------------------------Size-------------- ---•-------Liquid depth-------------------------.Capacity----------------------- Dispos i 1 istance from nearest well, , i from foundation--------------------Distance to nearest lot line____________.._._ umber of lines--------------------------- ------Length of each line--------------------- -------Width of trench--------------.--------------------- Type of filter material----_____________________Depth of filter material-----------------------Total length------------------------- �- y f Seepage Pit: Distance to nearest well____________________Distance fr foundation_/d-------------Distance to nearest lot lin'e----___~ Number of pits._..________________Lining material ___ (-__.Size: Diameter------ Dept'n------___- ----------- Cesspool: Distance from nearest well----------------- from foundation------------ -------Lining material--------------------------- ______- ❑ Size: Diameter---------------------- ---------------Depth-------------- ------ -----------------------------Liquid Capacity----------------------------gals. _____Distance from nearest building ----------------. Privy: Distance from nearest well.-----------_----- ------------------------ g--------- - ----------- ❑ Distance to nearest lot line--------- ---------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------------------------ ------------------------ ----------------------------------------------------------------------------------------------- --------------------------------------------- 1 hereby certify that I have prepared this p Ii tion and that the work will be done in accordance with San Joaquin Countyf ordinances, State laws, and rules and regulatio o the San Joaquin Local Health District. / (Signed) - ------ ----- ------------- --------- -------------------------------------------------------- --------(Owner and/or Contractor) By:------------------ •-------------------•-- -- ----- - ---- ------ - ---------------------------------------------------(Title)---------------------------------------------- -- ---- ---- --- (Plot plan, showing size of lot, ocation o stem in re ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- . --- �s ------------------- --------- DATE '2`5 C REVIEWEDBY---------------------------- ------------------------------------------------- --------------------------------------------- DATE-------------------------- --- ----------------------- BUILDINGPERMIT ISSUED------------------------------------------- ------------------—-------------------------------------- DATE------------------------------------------------------------- Alterations and/or-- reco m dation : -- -------------- ------------------------------------- -•---------4 - ._._ ' � T FINAL INSPECTION BY:..----- Date _- - -`i~�-4� ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 P.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California rG 9 REVME0 13.59 3M 3-'63 F.P.CG.