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FOR OFFICE USE: +� �00<0 L 0SI ,^1 7- (k _______________________.__.._-___________________ APPLICATION FOR SANITATION PERMIT Permit No. .. ---------------------------------- ------------ (Complete in Duplicate) 7� / ______________________________________________________ I This Permit Expires 1 Year From Date Issued 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 L TION-------------------- - ------- ---- ------------ -------------------------------------- Owner's Name '' '------ T ...e%•--r---`=' -mac------------------------------ -----. Phone.................................... Address �` �— y� ------- -•' i� ' � ------....0 -------------------------------------------------------- Contractor's Name------... ----------------------------------------------------------------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other ❑ Number of living units: ...r___ Number of bedrooms ___f___- Number of baths ___I___ Lot size S�L�:_: _-..------- ��.-0 -------- Water Supply: Public system ❑ Community system [M Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay)d Adobe ❑ Hardpan Previous Application Made: (If yes,date--------------------) NoNew Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_f©P__f_-Distan fro o ndation___6Q__._...._.Mat `i _ f-"_._._.____. P _ l-- --- No. of compartments _ j _ .Li' uid de th_..___ ..____..Ca aci �� O P Size �•------- - q R P ty---- -- ------- v Disposal Field: Distance from nearest well_./0-0-1-Distance from foundation----s�--P....._.Distance to nearest lot Ii __�2..._.____. ( j Number of lines-------T_. ___-__ _ ---___Length of eachline1 'Z!i._Z.?bVidth of trench-----A-—_ ________________ Type of filter material .-f -----' -- :Depth of filter material____/_-----------Total length---S.6_______________________________ :s Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_____.__-__-____- �(^ ❑ Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Dept h_-__-_.__-_--_.._-___.--_____--_- 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--------- ------------------------------------------------------•---------------•----------------•-------••----------------------------------- Remodeling and/or repairing (describe):--------------------- --------------------------•------•-------•----•--------------•--•---------........................................................ -•---------•-------------------------------------------------•-----------------------------------------------------•------------------------------------------ ------------------------------------------------------ ------ --------------------------------------------------------------------------------------------------•--------------------------------------------------------------------•-----•------------------•-•-•------------------------ ---------------------------- ---------- ------.----------------------.--------------------------.----.------------------------------------------------------------------.--•---•--------.----•--.------------------.----- 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 rules and regulations of the San Joaquin Local Health District. ` ' / N c, (Signed)----- -----------------------------------------------------------•--------------------(Owner and/or Contractor) 1 - ---------- ,..... I - --- --f B Vii' l - - Y• : . -- - - - --------•..(Title)--------------------------------------------- 1 (Plot plan, showing size of lot, location of system in relay wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------------------- = -- ° ---- DATE-----• REVIEWEDBY------------------------------------------------------------------------------------------ -------- DATE -- = BUILDING PERMIT ISSUED---------------------------------------------------------------- v------�' �--- , ------------- Alterations and/or recommendations:---------------------------------------- ---------•-----------------------•------------------------------------------------------------------------- ----------------------------------••----------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------•-- ------------------------------------------------------•------------ ----------------------- -------------------------------------------------------------------------------------------------------------------- ---------- --------------------------------------------------------------------------------------------------------------------------------------- ••-----------------------------------------•----------------------------------- ---------------- --------------------------------------- ---- -------- ------------- --------------------------------------------------------- ----------------------------------- -- ----- FINAL INSPECTION BY:.----- -------------------------------------------- Date. ------------------------------1 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 REVISED 8-S9 3M 3-'63 F.P.CD.