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AUK U�FIC;EU4E -------------------------- ------------ APPLICATION FOR SANITATION PERMIT Permit No. ../� . --------------------------------------------------------- (Complete in Duplicate) /7✓ --------------- - This Permit Expires 1 Year From Date Issued Date Issued ---- Application is hereby made to the San aquin Local Health Di rict for a permit to construct and install the work herein described. This application is made in complian o 0n o. 549. JOB ADDRESS AND O ATION ------ - wir- Owner's Name---- -- Ph ne-------------------------- Address..-__/ Contractor's Name------- -- - ------ • -- -•-- -------•--------------------•---------- ---------•------•-------------- ---------- Phone----- ----------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other fir' Number of living units: _J-_- Number of bedrooms --— Number of baths � _ _ Lot size _ _ Water Supply: Public system ❑ Community system [❑ Private epth to Water Table _left. 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 F---J FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - r (No septic tank or cesspool permitted if public se`w'er is available w4hin"200 feet.) / N. Septic Tarr k: Distance from nearest �_ _ DistarrLce fr'am fqun jation__,l�__._._r_Materiaf__[ �- �/ No. of compartments___ _ ---------- Si Igid de`th-----4 -- ---------Capacity ---- Disposal, Field:[ Distance'fiom nearest-well-V047 Distance-from .foundation__`A___--____9istance to nearest lot line---"^��___Number of lines__ / ------- -.-- -length of each linef _,�it� / Width of trench-_ ------------------------- ["� s� Type of fiat'r material_ / Depth of filter material_f--!r- Total 'lent �- See a e Pit: p Dkistanceyto nearest well----------------------Distance from foundation-------------------Distance'-to nearest lot line-----.________-,. ❑ ' Number of pits-_------------------Lining material-----------------------Size: Diameter----------.------------Depth--------------------------------- Cesspool: Distance from neare9t well-----------------Distance from foundation--------------------Lining material'._.__--._____..____._ � ------=-------- ❑ Size: Diameter------------------ -------------------Depth---------------------•-----------------------------Liquid Capacity----------------------'-----gals. Privy: Distance from nearest well------------------.-._.---------------------------Distance from nearest building---________-_--_-___________-_-_._.____._. ❑ Distance to nearest lot line Remodeling and/or repairing (describe):----- -/Jr ,/ ------- s 4�, -�-----/-- ------------•------------ ---------•---------- -------------------------------------------------------------------------------------------------------------y-----t • ----------------------------------------P4 -------------- ----------- ------------------------------•------•------------------------------------------ -----------------------------------•-•----I--------------------------- -------------------------•------------------------ -------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules rd regulations of the an Joaquin Local Health District. (Signed)------------------- --- -- ------------------ r Contractor) By:------------------------------------------------- --------------------------------------- Ti+le - [Plot plan, showing size of lot, location of system in relation ells, buildings, etc., can be placed on reverse side). c FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --•-------------- ----------------------------- •{ �-�------ DATE---- , ' - REVIEWED BY-------------------------------- ------------------------------ -------------- - - ----------------- r--------------------- DATE-------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------- ------------------------------------ DATE---- --------------------------------------------------- - Aiterations and/or recommendations:-----------------___-----------_. ___._. . - _! _ _ ,J �j,- - J, r'{�- ---- ------------- -------------••----------------------------------'- I 1 ' -- - c �4--------------------------------------------------------'-------- --------- -------------------•-- ------------ = % I FINAL INSPECTION BY--------------------- -'=`=-- Date.-------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California A Tracy,California ti ES 9 REVISED B•54 3M 3-'63 F.P.Gp. �� '