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FOR OFFICE USE: ------------------ ----------------------- -------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _11...........� --------------------------------------------------------- {Complete in Duplicate) ---. 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 a/nd install the work herein described. This application is made in compliance with County Ordinance No./549. F JOB ADDRESS AND LOCATION . f 1--�_ ------------- r------ 9-�/ =------------------------------------- Owner's Name----- - - ----------•------------ ---------------- Phone_'. .. d ------------- ....... - -------- Contractor's Name- - r--_.,�. ------ -------------------------------- -------• --•--_. Phone-----•----------------- Installation will serve: Residence [P Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: __1----- Number of bedrooms _, .._ Number of baths ;_ Lot size -____________________________ Water Supply: Public system ❑ Community system ❑ Private.RJ Depth to Water Table �a_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ dobe Hardpan ❑ pp ( y ) No,,* New Construction: Yes4 No ❑ FHA/ es ❑ No ❑ Previous Application Made: If es,date__.._._____..___._. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weil_ 1'�___ ___Distance fro} fou_dat'son__. _________.Material_____________ _________ No. of compartments---A--______________ _ ____ _ ______Liquid depth_______ 1� ___ _ ____..._____..Capacity_ __ Size_ y1 Disposal Field: Distance from nearest well ------Distance from foundation----/_Q _-_._-.Distance to nearest lot ! e__C2 ___._.... Number of lines------- —.._... __ Length of each line----- _ __ �_-_._.Width of trench___. '_ �---------------------- Type of filter materi _Depth of filter material----/_�-_-_-_____.Total length—?_-06--------------------------- g page Pit: Distance to nearest well._.1/t'27.---_.-._Distance 4f �Wff ndation_�#. -__._-Distance to nearest lot line.____.______T Number of pifs__�--_-_____-____Lining material-_-_ _..Size: Diamefer____33.ff_____Depth____'�__.-_S----______________ 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 and/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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) � / ----- ---------- ----------------------------------- --- -------(Owner and/or Contractor) Y•--------------- (Title) plan, showing size of lot; I Ion of systelrs'in >`elation to-wells, buildings; etc.;--can be-placed on-reverse side).---- (Plot FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--//I-!;- -- ----- DATE---- _------ r___._..______-_------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--------------------------------- -- • ----- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------- -------------------------------------- Alterations and/or recommendafions:------------------------------ ---------- - ---------------------------------------------------------------------------- ----------------------•----------- ----------•--------- ------------------------------•---•-------------------------------------------------------------------- ---------------------------------------------•---------------- -------------- -•--------------- ---------- -------------------------------------------------------------- --------------- --------------------••------------------------------------- -------------------------------------------------------:------------ FINAL INSPECTION BY:. - ----------------- Date----1 _ rKr.--------- ------__ ---------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselten Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 arviseo a-ss 3M 9-•63 r.P.co.