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FOR OFF EUAE: - ----------------- -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..1. - .f........... ----------- ----------------- ------------- ---- ---- --- (Complete in Duplicate) C 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 zzC/ountyyOrdinance No. 549. _� � JOB ADDRESS AND LOC TION____ _-- - ----._ Phone--------------------------------•- �Owner's Name ! - Address------------ZZ` WO -------------------- ------------------------------------------------------------------ ------------- - _------•-•---- � �Contractor's Name------------- -- --------------------------------------------•-------------------•----------------------- Phone----------------------------------- Installation will serve: Residence [!r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�...__. Number of bedrooms ___Number of baths ---1---- Lot size __`S---1�--_ Water Supply: Public system ®Community system ❑ Private ❑ Depth to Water Table _ -0-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �ardpan ❑ Previous Application Made: (I€yes,date--------------------) 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.) r- r Septic T k: Distance from nearest well____ --------Distance from foundation__ _ B________..Ma _erial----- ------------------_-_----------__ No. of compartments__ -- depth____'__r_____.-.______._Ca Capacity kaD_q_ —v f i DisE field: Distance from nearest well____--______Distance from foundation__?__________-Distance to nearest lot line- ------ kill Number of lines--------- ------------Length of each line___-9_0__l------ ---------Width of trench----'ZS(__-- _______-___-_____ Type of filter material Gc [_____Depth of filter material-----x$:_y______-Total length----hLX!______2'C>_-`_______--------- Seepage Pit: ________SeepagePit: Distance to nearest well___—______________DistanceAom foundation_�4___________-_��ante to nearest lot line_-ti?-4_______ Number of pits----I----------------Lining material__-_J__4G-�------Size: Diameter_-_ _.___-------------Depth__-'��__________________-__ Cesspool: Distance from nearest well-_________-____Distance from foundation--------------_____Lining material-,------------------------------------ Fl ______-____________-____________-❑ 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)------------------------------------------------------------------------------------------------- 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 rules and regula -ons of the 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----- -------- F --,4-e_4i-'----------------------------------------------------------- DATE--------�.-- -_7 4� 3'_--------------------- REVIEWED ---------------------- REVIEWED BY---------------------- ---------------------- ------------- ------------------------------------------------------- DATE-------------------- - ---------• --------•------ BUILDINGPERMIT ISSUED--•------------•------------------------------------------------------------------------------------- DATE---------------------------------------- -------------------- Alterations and/or ecommenAati n �1 '-------------------S---/r•----------------------------------------•---•---•---------•--------------------------------------- ---------- --------------------------------------------------------- ----------------------------------------------------------------------------------------------------•---•-------------------------------------- -------- �-s= ------ Date_---- -f FINAL INSPECTION BY:----------- -- - ------------- / �----�-� ---- --------- -- --- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'83 F'.P.CD.