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11 1..�S ____________________________.--..----------------- -------- -____--________. APPLICAT0N FOR SANITATION PERMIT Permit No. ___......_......_. .. -------- -----------------::----------------------------- (Complete in Duplicate) ��' f �/ --------------------------------------------------------- This Permit Expires 1 Year From Date Issu Issued ---------------�-4� 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 No. 549, d0 O.-ZS e- :323 { �. �T_A''f�J7— dO I - /'L` _ ► JOB ADDRESS A .D LOCATION ___? - _X4_74-j _-_- -'I'e' -- eK-- = ...... _ ----------- Owner's Name.! _ - : . w ------------------------------------------------------- Phone------------------------------------ Address ...... -------------------•---------------Address.__.... ------------- : -"- G "` - zo _----_-------------------- Phone-----------------------••-------•- Contractor's Name ----- - -- _ Installation will serve: Residence (Apartment House ❑ Commercial [3 Trailer Court [❑ Motel ❑ Other ❑ Number of living units: __1-____ Number of bedrooms ]OV Number of baths __ Lot size __ - - -t----— Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table ________ ft. , 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 ❑ FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) It f Septic ank: Distance from nearest well_t�--__ -___Distance from foundation__.__�_P_-.._.._-Material___C� /+,•� 1 ___________________ No. of compartments........ -------------5ize `l:__e�_/4��Y_s----Liquid depth-_--_ _�.--.------____._Capacity_}_ -_9f'_ s Disposa field: Distance from nearest well ___?k-.r__.Distance from foundation..--1-b.- -_----Distance to nearest lot line- �} Number of lines-----------I__------- ________Length of each line-----l41�__`__-_--___--_.Width of trench.------;r?----`_-. --------------- Type of filter material_ ----_--Depth of filter material...... Total length------- Q C?-----___________________ Seepage Pit: Distance to nearest well ___Distance from foundation____f _____._..Distance to nearest lot line__.-�--._--._ [ Number of pits._..-__-_r__-.._ Lining'materia)/r7.L '_...Size: Diameter-____—_1 Depth____-A�_�____________________ _.. Cesspool: Distance from nearest well----------------;Distance from foundation--------------------Lining material__._.__----____________.________-___ ❑ Size: Diameter--------------------- ---------------lDepth-------- - ------------------------ - -------------Liquid Capacity-- --------------------.-.--gals. Q Privy: Distance from nearest weFl ..'_......... ................................Distance from nearest building.-.--------------------------------------- ❑ Distance to nearest lot line: �"--------------------------------------------------------------- --------------------- -----------------------•--------------------- s _ Remodeling and/or repairing (describe):---_-'.' ------ ---------------------------------------------------------------------•---------------------...------------ ---------------••-•------------•----._---------------------------------------------� ----------------------- ----------------------- ------------------------------------------------- ----------- -----•-----------•------------------------------------------------------g-------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State .ws, and rules and regulations of the San Joaquin Local Health District. n z ---- (Signed, `�` ._. ------I---��--- - --�'- �`�-- --------- - -- ' nd or Contractor ------ < / ) e 7 --- (Plot plan, showing size of lot, location of system in rect - -- ion to wells, buildings, etc., can be placed on reverse side). r r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --------- -------------------- ---------------------------------- DATE--- ----------------------------------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------ ------------•-•- BUILDINGPERMIT ISSUED--------------•--------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or-recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ---------- ------------------------------------------------------------------- ------ -------------------------------------------------------------------•--------•------------------------------------------------- --------- �. . ---------------------•--- -------------------------------- -------------------------- --------------------------------•---------------------------•------------•---•---------•-----------------------------------------------------------------------------------•-•------------ FINAL INSPECTION BY: _ __ ____ _______ _ ------------------------ Date----- -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REViSEO 6.59 3M 3-'63 F.P-C6. 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