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FOR OFFICE USE: Llfal --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ... .r�. ... --- ------------:------------------------------- (Complete in Duplicate) Date Issued ..-_-_---_....----._...._--------- ----------------- 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 N 549. JOB ADDRESS AND L ATION----`------------------------ I.... -� --------------_---------------`. ....... -------- - � Owner's Name. t * �Zr�`'Q Phone------------------------------------ ----------------------- Address--------_-_--- 2 -= D . . Contractor's Name-------------��- >�=211 f Phone................................... Installation will serve: Residen Apartment House ❑ Commercial ❑ Trailer"Court ❑ Motel ❑ Other ❑ Number of living units: ...../+_ umber of bedrooms .--VNumber of baths __--.-. Lot size ------ ....................... 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--------------------) NoNew ConstY ti n: e ❑No FHA/VA: Yes [I No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ptic`Ta k: Distance from nearest well-----------------Distance from foundation__._-.._.-_---_-...Material-......._..._..-...._-------...._.-----._..._---- No. of compartments--------------------------Size-----_------------------------Liquid depth--------------------------Capacity.............•--------- Dispo al Field. Distance from nearest well_IZ?Z /_Distance from foundation..J,'Z,.......Distance to nearest lot li al_-._4':'._.__. Number of lines----- .l,.._..-------^,-_Length of each line� -. .:T 1 dth of trench---2----- ------------ ----- Type of filter mate ria l_�7_j . _Depth of filter material_./__ r_._-_-----Total length_.-_..7-......................... 6Z_111Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line__.._.-.._.-._... ❑ Number of pits......................Lining material-----------------------Size: Diameter-----------------------Depth.....---------------.._...------ \ 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------------------------------------------ R :_-_ ... .._...❑ Distance to nearest lot line--------------------------------------------------------------•---•---••-----------------------------------------------------------•------- Remodelingand/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 1" ordinances, State laws, and rules and reg ations of the San Joaquin Local Health District. f r (Signed)._----------- ..... - ------------------------------` '- ------------------- ----------------------------------- --------------------(Owner and/or Contractor) • 1 W 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 APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE------ -- -------------------------------------- REVIEWEDBY------------------------------------------------------------------ ;---- -----•--•------ DATE , ��' -- 1------------------ BUILDINGPERMIT ISSUED------------------------------------------------------- ------ DATE------------------------------------------------------------ Alterationsand/or recommendations--------------------------------------- -----------------...................................................................................--------------_- -•----------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- --------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ------------------------------ ---------- ----------------- ---------------- --•------------- ----------------------------------- --------------------------...------------------------------------------------------------------------------------------------------------------ '; ( ° 4 / QQ _ � FINAL INSPECTION BY:- -- ------ - -- t 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 B-59 3M 3-'63 F.P.DD.