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FOR OFFICE USE: '. ----------------------------------- q APPLICATION FOR SANITATION PERMIT Permit No. ../1---l/__ .__. ------------------------------------- -------------- - (Complete in Duplicate) // ,/ l• Date Issued --------------------- -__.__.__-__--------------------- This Permit Expires I Year From Date Issued !mss'" Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thisapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION ` "� Owner's Name g - ------ � . ............ --------------------------------------------- ----- -- Phone------------------------•-•- ��- Address_..-------O- -----_---��-------• y -------- ---------- ="'-----------•-- ---------• --------------------------- •----....-----------------•------.._..---------=---.. Contractor's Name _ --------------------------------•------------------------------------------------------------------------•-•----------._. Phone. :.... Installation will serve: Residence* Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms ___ __ Number of baths _/----- Lot size . `"6' '-------------------------------_- Wa+er Supply: Public system ❑ Community system ❑ Private LL Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel.0 Sandy Loam* Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan;C1 Previous Application Made: (If yes,date____________________l No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ NO-0 TYPE OF INSTALLATION AND SPECIFICATIONS: [IVa septic.tank.or,_cesspool_perrnittedYif public.sewer-is-available within_200 feet.)- .- ,4—_., Septic Tank: Distance from nearest-well-----------------Distance from foundation--------------------Material_____________-_-_____-___________________:____- ❑ No. of compartments ; Size------------------------•-------Liquid depth-------------------------.Capacity----------------------- Disposal Field: Distance from nearest well------------------Distance from foundation---------------------Distance to nearest lot line--------------- 0 _____---- --. { + ❑ Number of lines-----------------------------------Length of each line---------------------------._.Width of french-_.___.______-------_---__--------- i= Type of filter material- t --_Depth of filter material_______________________Total length----------------------------- S Distance to nearest welL____�d__4---Distance from f undation__2-0_�___.D�tance to nearest lot line_C�_+_ 1 ❑ Number of pits------1--------------Lining material-- -----Size: Diameter- ---' -�- ' Depth----1'-�}- -----------=__-.- Cesspool: Distance from nearest 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----------------- -------------------------------------------------------------------------------------------------------- ------- ----- Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ---------------------------------------------- ------------------------------------------------C----------------------------------- ------------------------------------------------------------------------- ---------------- --------------------------------------------- ---- ----------------------------------------------------------------------------------------------------------- ---------------------•----:----------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules andre ulations of the San Joaquin Local Health District. (Signed)---- . _ ems (Owner and/or Contractor) •�:_ ---------------------------- --------------------- ----- {Title) A_ _ (plot plan, showing size of lot, location of system in relation +o wells, buildings, etc., can b placed-on-oh s4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- �___ ------------------------------------------------- DATE-- -------�_^' 'lo_e-------------- REVIEWEDBY-------------------------------- ---------------------•------ ---- --------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------- ------------------------------ DATE. -------------------------------------------•---•--- Alterationsand/or recommendations:------------------------------------------------•-- ----------------- ----- ------------------------------------------=----------------------------=------ FINAL INSPECTION BY:--- ..-G -------------------------------- Date--- --- /�� .-- ----------------------- ,�f"s 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 ES 9 REVISED 8-59 3M 3-'63 F.P-CC.