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FOR OFFICE USE: ----- - -------------------------------- / q -------------------- ----- ------ ----`-_ ..__..__.___.___-._________ APPLICATION FOR SANITATION PERMIT Permit No. .., f �_.. --------------- ---------------- (Complete in Duplicate) — --- -------- -4 -------------------------------- --- This Kermit 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. " .,.Application application is made in compliance with County Ordinance No. 549. ZZZ JOB ADDRESS AND LOCATION_.. _ _ __ n� 7- JOB - ---- -------- ----- ---------------------------------------------- _.s ------------------------------•---. -------- � .. = � - --------- -- Owner's Name----- -- ----- Phone. - Address -- ---- - -----�- ----------W ----- --- --- ----------------- Contractor's Name ------------------------•----------------•- •--------------- Phone----••---•------------------------- Installation will serve: /esidence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _'___ Number of bedrooms 3. Number of baths Lot size _,/ _-----,,�f _ .2 --------- Water Supply: Public system El Community system rivate E] Depth to Water Table ft, k Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam ❑ CI y E] Adobe ardpan El Previous Application Made: (If yes,date -------------- No New Construction: Yes No ❑ FHA/VA: Yes ❑�IVo ❑ C TYPE OF INSTALLATION AND SPECIFICATIONS: y (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1' r Septic T Distance from nearest wel .Distance from foundation,,)__9_�.------Ma.teriai ._j3r�_C-_ __-_-._. � No. of compartment _ __ SizE/AJ _ -Liquld jepth--- 4 Capacity r r. J Disposal d: Distance from nearest well_ istance from foundation ____ Distance to nearest lot ------ Number of lines--------- -__________________Length of each line_ �$__tt�� Width of french.._C _ ____---____________.____ Type of filter material_Yj)C_} De th of filter mateal__/_�__-_____- Total length---�-�__________________________ ri Seepage Distance to nearest well __________-----------Distance from foundation-.,/ __.r__..Distance to nearest lot line ------------pits-------- material--- r-,33.. 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 ------------------Remodeling and/or repairing (describe)-----------------�-- I _- -------- •S�P�--z �.-------------------•-------- r --------------------------------------------- ---------------------------------------------------•-•--------------•--------- ----------•--•------••--------------------------------•------------------------------- ------- ,-#% r ------------------------------------------------- -- --- - -------------------------------------------------------------------------------------------------------------------------------•--------------------------------- - I hereby certiy at have prep r d^t 'application end that the work will-be done in-accordance with San Joaquin County ordinances, Statet1b' ,/,11druIes an r gula s of the San Joaquin Local Health District. (Signed) ----- c_f (Owner and/or Contractor] Sy' Il!_T` (Title] • a (Plot plan, showing size of lot, 0catian of system in relation to wells, gs, c., can be paced on reverse side). F EPA TM T USE LY APPLICATION ACCEPTED B ---- ------ -- - ------------------------- DATE REVIEWED BY ------ :: " ----------------- DATE- - ------' ----------------------•------------- BUILDINGPERMIT ISSUED--------------- ------------- ---- --------- ----- ----- ---- ----------- --------------. DATE. ------------- ------------------------------------------ Alterations and/or recommendations: ___' .__ = ----------------------------------------- --------------- !a ----------------------------------- ------ ---- ----- ----- --------- --------------------------- FINAL INSPECTIO =BY: .. 9 ^ ` ---- ---- - Date-`✓-_--- l�-1--------- -- - ------ SAN OAQUI LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street I Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED t3-59 3M 3^'63 F.P.CO. e