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FOR OFFI. E USE- 1 a. :p (f� 6 ----- f ___-___-_ APPLICATICSN FOR SANITATION PERM Permit No-------------- - ------ ------•_.,----------'----- ----------------------- (Complete.in Duplicate) ---.- This Permit Expires I Year From Date Issued Date.lssued Application is hereby made to the Saiol Local Health District for a permit to construct and install the work herein described. This application is made in compliance i 4ounty Ordinance No. 549. - JOB ADDRESS AN LOCATION------------------- --1--f---�--------------------- - --------- �-/ Owners Name- / ---------------------------------------------------- -- --- ----'"Phone---------- ,p ---- f Address -•- ----------------------------------------------------......................------------------------------------ ------ _.. :._.... k - ' Phone----------------------------------- Contractor's Name__ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.__./. Number_of bedrooms__ Number of baths ---/_..Lot size _________ �--�------------ Water Supply: Public.system �Commuriifiy system ❑ Private ❑ Depth to Water Table ` ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe ff-Hardpan ❑ Previous Application Made: {if yes,date-------- --------- 'No E< New Construction: Yes YNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - f Septic ank: Distance from nearest well--- ------------Distance from foundation^_I0.._________.Material__f__._,__.___.-.------------------------------- No. of compartments----_rte-------------------Sixe__3__' - ,J-..Liquid depth--- -------------------Capacity...kDa,F-------- Disposal Field: Distance from nearest well--'-___-___.._.Distance from foundation-Za_-_______---Distance to nearest lot li e):C [ Number of lines------'�.-:- --------------------Length of each line-----'�D-- -------Width of trench-__.____1-_-------------_------- I a - _ Type of filter material__[ _10 _ -_____Depth of filter material___ ________________Total length___. __Q___.________ ________________._ j Seepa Pit: Distance to nearest well___ _______ --- _ — "_______._Distanc�e;from foundation_ p_____________Distance to nearest lot line__._____.._ Number of pits.__________ --_Lining material !1W(---.---Size: Diameter-_. Depth------ ____'_______________ Cesspool: Distance from nearest well-----------------Distance from foundation -__________._.____.Lining material-----------------------_.'___ ❑ Size: Diameter-------------------------- ---------.Depth------------- -----------------------------------Liquid Capacity----------------------- g Privy: Distance from nearest well--------------------------------------------------Distance from.nearest.building------------------------------------------ Distance _______________._ _.-- Distanceto nearest lot line-- ---------------------- -------------------------------------------------------------------------------------------------------------------- 1 � f Remodelingand/or repairing (desclribe)------------------------------------------------------.-----------------------------------------------------------..------------------------------------- -------------------------•-•--------------------------------=----------------------------------------------------------------•------------------------------------------------------------------------------------------------ `--------•---------------------------------------•-=---1----------------------------------------------------•-------------------•--------------=------------------------------------------------------------------- -----------------------------------------------------------------------•--------------------------------•-----------------•----------•------------------------------------------------------------------------------.. ion and that the-work will be done in accordance with San Joaquin County I hereby certify that I have prepared this applicat x ordinances, State laws, and rules and regulati s of the San Joaquin Local Health District. --- =----- -- - Owner and/or Contractor (Signed)----• ------------------------------ - - - ( � ) By=----------------------------------- --------------------------------------------------------------------------------{Title)--------- ------------------ --------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r R DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-.-.- ----- -- ------/I-�- --..----------- ---------------------------------------- DATE---------- -------------•------- REVIEWEDBY----------------------------------------------------r----------------------------------------------------------------------- DATE----------- -----------------------•----------------------- BUILDINGPERMIT ISSUED------------- •-----------------------------------------------—------------------------- ------------ DATE------------ ------------------------r------------------------ Alterationsand/or recommendations:----------------- ------- --------------------- -------------------------------------------------------------------------••------------ ----------------- -----------------••------------ ---------------.-.---•--------------------------•------------------------------------------------"-"----------------•----------------------------------------------•----•---------- ----------------- ------------------------------------ ------------------------------------------------:-----------------------------------------------------------------I----------------------------------------------- ) �• E t _____ ___________ _________________________________________ ___ ________ _________.___.______ FINAL INSPECTION BY:----------I _-•---&e� C. �j. date__.. } l C3� SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 4 124 Sycamore Street` 205 West 9th Street Stockton,California I Lodi,California ` Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CC. 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