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FOR OFFICE USE: ------------------------ ----- ---------------------- - ----------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. --------- ---------------=--=--------------------------- ------- (Complete in Duplicate) J _________________________________________________________ This Permit Expires 1 Year From Date Issued / Date Issued ______ .� . . ,........ SDS' . Application is hereby made to the San Joaquin Local Health.District fora permit to construct and install the work herein described. ' This applicafion is made in compliance with County Ordinance'No. 549:; JOB-ADDRESS`,AID-LO ATION- -,--'�----��---------- - `� '------- �-e..,� - ------ �:1:�� Owner's Name-------- --- - -- ------- -------------------------•-----------/- Phone-----------------',�-- ........ Address------- ----------- --------------•--•--•-------------------------------- Contractors Name-•------•---------•-------------- - - ------------------ ------------------------------------------ ................ Phone.----•--•------------•------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _____ Number of bedrooms --9e' Number f baths __.E-__ Lot size Water Supply: Public system ElCommunity system E] Private Depth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan e ; Previous Application Made: lif yes,date--------------------1 No ❑ New 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----------------Distance from foundation--------------------Material---------------------------------------------------- ❑ No. of compartments--------------------------Size---------------- ----=-•--._:---Liquid depth..........................Capacity....................... Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_----;------_-x__;}`" ❑ Number of lines-----------------------------------Length of each line------------------------------Width offrench------------------------------------, 13 Type of filter material_______________________Depth of filter material----------=;__________.Total length------------------------------------------ � i Seep e Pit: Distance to nearest well------I-k_®------Distance m foundation----J_0---------Dis ante to nearest I t l'n%--�-- 3 I Number of pits--------I-----------Lining material---_-- Size:...Diameter------ -G_- �- Dep#h._ � ------------------- . Cesspool: Distance from nearest well-----------------Distance from foundation :_`--___.------.Lining material------------------ _--.-___---_ _-:' y, I ❑ Size: Diameter--------------------------- ----------Depth------------------------------------ -------------Liquid Capacity--------------------- -----gals. _ T Privy: Distance from nearest well----------------------------------------------- from.nearesf building, !-------------------------------------- 0 -- -.---_-_----___---_---_-----__._.❑ Distance to nearest lot line-- ------ ------------------------------------ --------------------------------- '---------- ---=--------------- �J i Remodeling and/or repairing {descr' e ____..._.____.__ ______..________________________________ ---- ---------------•-----------------------•-------------------------------- ---------------------------------------------------•------ ------------------ ---- - ---- ----------------------- -- •---•-•----------------------- = ----•-------------------------------- i ------------------------- ------------------------ - r------------------------------=-----------=--------•---------------------------- 1 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. (Signed)-----e- -- -------- c ------------------- ---------------------(Owner an oo By:.----:--------------------------------•----------------•--------------------------------------------- ----------------------------(Title)---------------------------------------- --- -- - - (Plot "plan, showing size of lotjocation of system in relation to,wells,,buildings,-etc.-, can be placed'on reverse side). ~ T FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- ---- -- - v---- -------------------------'DATE__-�._��'-G_�-------------------------------- - REVIEWED BY----------------------------------- --------- ------------------------------------- ------------------------------------------_DATE------------------------- - -- ---------------------------- BUILDING PERMIT ISSUED----------------------------------------------- -------------------------------------------- --------- DATE----------------- ------------------------------------- Alterations and/or recommendations------------------------------ n --------=�-=,/�4- 7 . FINAL INSPECTION BY:- ---------------------- Date__t�: t1._�(0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi, California s Manteca,California Tracy,California i i ES 9 REVISED 9-59 3M 3•'63 F.P.CC. I