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FOR OFFICE USE: 2 '1 � 1 ---------------------------------- --- - ---------- --------------------------------------------------------- ..................... T/`1 APPLICATION FOR SANITATION PERMIT Permit No. ..�................. (Complete in Duplicate) T ...-_____________________________._.._.__......------ 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 r � � `� �=f-C. tom`= JOB ADDRESS AND LOCATION._ ._ ......._._. Owners Nam Z`� ` =� ---�- ---w-----T---- =- --------------- -- --- ---- Phone...-.. --•--••. Address •- = --•-- •-- ----R -- f --------- � iy _._,G_..__.__ E"""r!.._..__. ................... Contractors Name....... = •----- Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... _- Number of bedrooms ---/--- Number of baths __j.... Lot size ......jC'.�__-_x- .<:I________________ i Water Supply: Public system ❑ Community system g 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 El"New Construction: Yes En-�No ❑ FHA/VA: Yes ❑ No E7 -__ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well_---- Distan from,foundat _-.-.lig_...._M to ial_ '1 C = ', No. of compartments < _--_ q Z p ..Size ! .-Liquid depth---- --�- CapacitY� � Disposal Field: Distance from nearest well.-- Distance from foundatio _._._( ...._.Distance to nearest lotjinej.__ �__._._ 0 Number of lines...... ........_._..._- Length of each line....... -'C.'.._ .- Width of trench:..-:_:_-.�I'--�------------ - 0 Type of filter material,.z1I.-f-4—Depth of filter material___. _- length Pit: Distance to nearest well._..------_--.--.--_Distance from foundation....................Distance to nearest lot line----------------- 0 Number of pits----------------------Lining material-----------------------Size: Diameter-------------.---------Depth-----._-._._._--.-._.--.--.._-.._ H Cesspool: Distance from nearest well----------------•Distance from foundation--------------------Lining material-------------------.----------------- p ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------galls. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building___._-_--..-.-_---.-.-.--_--.__.__-------. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------- ---------------------------------•--------------------------------------------------------------•-•---------------------------•----------------- -----•--•-------------------------------------------------------•--------------.....--------------------------•-------------- ------------------•-----------------------------------•----••-•-------------...-------...----- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- ---------------W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 17 ordinances, State laws,,and rules and regulations of the San Joaquin Local_Health District. (Signed) q,, .A� Y ------------------------------- --------------------- ------- - Owner and/or Contractor BY:......f �-_L - `i�_ ---------- ------------------- ----------------- ----(Title)------------- - ----- -- - -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------------- -- :. _ DATE-- -- ............. ------. ------.------------------ =_ REVIEWED BY DATE-2: mss_ BUILDING PERMIT ISSUED--------------------------- --------------------------------------------- ------------- DATE------------------------------------------------------------- Alterations and/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 99 9 REVISED 8-59 3M 3-•63 F.P.CD.