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FOR OFFICE USE: )Y®Q 9 APPLICATION FOR SANITATION PERMITPermit No. ./.....?fes --------------------------------------------------------- ....... . --------------------------------------------------------- (Complete in Duplicate) Date Issued -----------------______-----_----------_-------------- I This Permit Expires 1 Year From Date Issued 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. JOB ADDRESS AND LOCATION y-q----- -- J� ✓1 ----- •------------- . Owner's Name---------------- ------------•. •-------_� -- ------------------------- Phone------------------------------------ - _ -------------------------------------- Address........................ C`---- .. ------- r/ ------------------------•----------•------------- Contractor's Name ------------------------------------------------------ ------------------•- Phone.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _...____ Number of bedrooms __ --_ Number of baths -------- Lot size ----------- ---------------------- Water ______________________ Water Supply: Public system ❑ Community system K Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ClayX Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No J6 , FHANA: Yes ❑ No)A TYPE OF INSTALLATION AND SPECIFICATIONS: r7ff 'L (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic�T k; Distance from nearest well----------------_Distance from foundation--------------------Material_________-______--_____.___._-_-____._.._-__----. Al No. of compartments-------------------- -----Size-----------------------•--------Liquid depth_-------------------------Capacity----------------------- � isposal Fiplc(: Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line- El -)Number of lines___________________________________Length of each line------------------------------Width sof trench............. _____---._-____-._ Type of filter material_________________________Depth of filter material-----------------.-----Total length____-__-_________-__-----___-__----.--__.- �D Seepage Pit: Distance to nearest ell fem__4 _., ggistance fT fo dation.................... )'stance o nearest lot 11nerf.:�._.___-- Number of pits------�.___.._._- �mafierial..��, Size: Diameter_/( .1 _Depth__ D Cesspool: Distance from nearest well-----------------Distance from foundation._Uz-Y---------Lining- • - - ----- ------------ _ ..... 1-71 Size: Diameter.------ --- �--------.Depth,---- --------- - ----- ------Liquid- Capacity ............gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 171 Distance to nearest lot line--------------------------------------------- ------------------•---•-------------•------------------------------------------•---------------- W Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------•------------------ ------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- 1--------------------- --------------------------------------------- ------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 rule and regulations of San Joaquin Local Health District. (Signed)----------------------------- ------ ---------- ------------------------------------- (Owner and/or Contractor) ----------------------------- By:............-----------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------------ ---- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --- _ DATE... `'� ---------------------------------------------------------------------------------------- ----- ---------- -- REVIEWED BY-------------------------------------------- ------ ------------- ---------- - ----------- DATE....... '1 ---•---- ------------------ BUILDING PERMIT ISSUED----------------------------------------------------------------- - A_- DATE------------------------------------------------------------ ---------- Alterationsand/or recommendations--------------------------------------------- --------------------------------------------------•-••----•-----------------------------------------------------•- ----------------------------------------------------------- ------------------------------------ --------------------------------------------------------- .............------------------------------------------- ------------------ ----------------------------------------------- ---------•-- - ---.----------------- FINAL INSPECTION BY:. - Date � '.. - ------------------------------ 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.CD.