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FOR OFFICE U E: APPLICATION FOR SANITATION PERMIT. Permit No. ...__ ----- ------------ ---'--------------- c l (Complete in Duplicate) ` This Permit Expires 1 Year From Date Issued Date Issued ----:_ .A 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. e JOB ADDRESS AND L ATkON 1` -------------- --------- Owner's Name----------A -------------•-----------------=------•------------------------ ------------------------------------------- Phone----_--------•---------•---•-•-- Addresst --------- --- --------•----------------------------•-•----------------------•------•------------------• ----------••------•---------_--------------_-- Contractor's Name �__L_,_ Phone................................... {�'----k--- Installation will serve: Residence M—Apartment House,❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.c'1___� Number of bedrooms ----J_ Number of baths :1___- Lot size __________________________________ } Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _A?? ft. 4 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[Hardpan ❑ l i Previous Application Made: hf,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.) y� Sept Task; Distance from nearest well________________Distance from foundation--------------------Material-------------------------- -___________.________- No. of compartments-:---------4------- ------Size---------------------------------Liquid depth__----------------------Capacity----------------------- Disposal Fj Distance from nearest welly o+ne_____Distance from foundation..�A__------------Distance to nearest lot line----___________ Number of lines__________'____________ _______Length of each line__._:_____ Width of trench--------z�-r----'-----•--- Type of filter material�l --------Depth of filter.material'__A _`__________-Total length----------------±�------------------- Seepage Pit: Distance to nearest well------------------------ from foundation------___...........Distance to nearest lot line_-______________- [l] Number of pits-------------- ------Lining material-----------------------Size: Diameter-----------------------Dept h--------------.----•--------------- Cesspool: Distance from nearest well------------------Distance from foundation---------------------Lining-material___.____.___:_..-._____________...___. ❑. Size: Diameter'--------------------------------------Depth-------------------•------------•- -----------------Liquid Capacity----------------------------gals. Privy: Distance fromnearest well-________________ -------------------------------Distance from nearest building----------------------------------------- ❑ , Disfiance to nearest lot line------------- ------------------------- - -------•----------.....-------------------...---------------------------••--------------- Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------- ---------------------------------------------------------- f --------------••--------------------------------------------------•------------------------------=------------------------------------------------------------------------------------------------------------- ------------- ----------•----------------- ---------------•-----------------`-•• - -------------•--------------------- 1 ------••----------•-------------------------------•------------ ------- I hereby certify that-I have prepared th• application and that the work will be done in accordance with San Joaquin Coun+y I ordinances, State laws, and rules end r gul ions of the San Joaquin Local Health District. i a (Signed),--. '# {Owner and/or Contractorl g By:---------------------------- ------------ - ------- -- ---- "a p -----------------•------------------{Title)----------------------------------------- - - --------------- F (Plot plan, showing size of i cation of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - �! M = Z_ DATE CREVIEWED BY------------------------- --------------6------------- --- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED-------...-•----•----------------- – --------------• DA = Alterations and/or recommendations------------==--------------------------=----------•-•---------•--------------=--•._-------------------------------------------------------------------••------ -------------• --------------------------•---- -----------------------------------------------------•----------_----------•• ----------- is3 ---_-••------------•-•----------••------------•----------------------------------------------------------------------------------------------------------------------------------------------------••----_------------------- ------------------------------- ------------------- • •------- --------------------••----------•----------- Date 4 r FINAL INSPECTION B / I SAN JOAQUIN LOCAL HEALTH DISTRICT t 130 South American t 3.00 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB-9 REV....9-59 r.P.CC.2M 6.64 1 F