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FOR OFFICE USE: kt -----------------------I--------- ------ ----- -- -------------------------------------- ------__________________________________________________---. APPLICATION FOR SANITATION PERMIT Permit No. ....l.._ � -------------------------------------I------------------- (Complete in Duplicate) / - -----------------------------------.---------------- --- This Permit Expires 1 Year From Date Issued Date Issued �s3 _ 30- Application is hereby made to the San Joaquin Local Health District for a permit to construct andel lir sIh ll 9e w Wr erein described-.- This application is made in compliance,1with County Ordinance No. 549, ' 4 JOB ADDRESS A LOCATI N- � Owner's Na -----=-- - - •- =------ - -- 1 ---- • --. ----••------- ------•----------- � -------------- ------- -------- ----=------ Phone------------------------------- Address__... �.. ....f s �� .... ` t - --- -- ------ ------ ----------- -------•------------------------------ ------- `-------------------•---- Contractor's Name------ ---------------------- ---- t r -. t ---.- Phone Installation will serve: Residence ' # Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ___ Number of bedrooms_ Number o aths --_-_-_- Lot size ___ �_��_ _____________________ Water Supply: Public system [❑ Community system ❑ Private Depth to Water Table __ ___, f#- Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Cla Adobe t Hardpan p , ❑ ❑ Y ❑ Y Y ❑ ❑ ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or,cesspool permitted if public sewer is available within 200 feet.) .} - 1' No. of compartments Size anon Material._... Septic Tank: Distance from nearest well-----------------Distance from found q d de th-_______t____. Capacity ❑ P ------ --------------------- ce from nearest well._--------_------Distance from foundation---_ - P p _Liquid ___________._...Distance to nearest lot line___-,_�f_____. , Dis❑oral Field: Number of lines: '--------------------------------Length of each line_______._.__ f' Numb ---- ---- --Width of trench filter material___-•___--_-_-___...._--Depth of-filter material-----------------------Total length-_.._.-__.__________________.______'____-- r Seepa e Pit; Distance to nearesf well.. 1D0_Distance f oundation____ __ ___ PV _._.___Distance to nearest lot line-__..--.--_..- Number of pits-��----------Lining material______________ ________Size: Diameter.-�-� -_ - ❑ -. ---.Dep th- -�.s_r_____-----_-,- Cesspool: Distance from nearest well from foundation____ .___--------_.Lining material--.----___-__.-_.-._-_-�__._, Size: Diameter---'--; Depth, _ ____ _ --------------- --------------- Li uid Ca acitY------------------ I ---- gals. , Privy: _ Distance from nearest well-____:._ ------------------ --------------Distance from nearest building -------------------------------- Distance to nearest lot line = p ` ' ----=------------ t ---------•------ ------ ' R—cmodeling-and%or repairing (describe) -- ------ ---- -•------------ ---••- ------------------------ --------------------- ----------1d, -------------Y________________�--_-------_-___----_-_--__----_.-_-_-_----__---- _. -----_-_-_-__-___.-.__-._-__--_--._------- --------------------------__----_____-----._--.._----_--_-_-__--_--_------______..____ ------------------------------------------------------------ ------- -- ------- ------------------------------------ _ ___-__ --.-__--_. ._ _ --__ __ ,.---__-__--_------__-__-_ -___--. --_ -"" .__-_----__ ------------- I hereby ce y at I have prepared this-application and the work will be done in accordance with .San Joaquin County 1 ordinances, St, laws, and rules and regulations of the San'Joaquin Local=Health District. I as' _ (Signed) --- _------ - -------------------------------- ract ) � _ � t BY-----------------w-; - - ------------- -- - --- -- --- ----------- ------ ----- -- (Title)--------- or Ont or (Plot plan, showing size of lot,:.locatioii o system inreat;in to wells, buildings, etc., can be placed on reverse side). iE i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY' ' ----------------------- -------- DATE--- .. f REVIEWED BY - A-----------=--- ----------------------------------,.---------------------- DATE------- % BUILDING PERMIT ISSUED: --------------=----:-,---.----- ----- t'--------------------------._ Alterations and/or recommendationsDATE = I :=-----=--- == - -------------------- --- E ----------------- - --------- --- ----- _ - - t v=-----•° ' ` = r ----------------- --------•"--------- --------------------- ---------------------------------------= ------ --------:-------------_- ---- - ------------- FINAL INSPECTION BY:.�i _ Date--- SAN -- ------- ------- -- Date r--- ---- --- 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 `. N E5 9 REVISED 6-59 3M 3•'63 F'.P.CD. 3�rF,�� _ L