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FOR OFFICE USE; -------------------:------------------------------ --_-------- -- ---------- - APPLICATION FOR SANITATION PERMIT Permit No. ..----/---�-r 7 -----------_ _ _ _______ _'___,_------ (Complete in Duplicate) 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 an install the work herein described. This application is made in compliance with County Ordinance No. 549. J013 ADQRESS AND LOCATION_-_ r �s� = Phone------------------------------- Owner's Name - --•------------------ - --------- : Address A- '---= ------0-ye-- £�-- Contractor's Name---- - _ Phone..._..--•-------------_.._.------- Installation will serve: Residence sEfl' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _______ Number of baths -------- Lot size ----------------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If 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.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material--------------------------------------- .__.____. ❑ No. of compartments------ ---- -------------Size--- -- Liquidp. ---�C;apacitY-------------- ------- from foundation_-____-.._..___.___.Distance to neare��ot line--------------- Disposal Field: Distance from nearest well______________._Distance _- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------- -- . Type of filter material------------------------- of filter material_------- .............Total length_________-.__-_.------------------------- Seepage Pit: -Distance to nearest well__/d7P-----------Distance from foundation---i_v-1-------Distance.fo nearest lot line--d---------- Number of pits-------I-------------Lining material-__ _Size: Diameter---- l�-------------Depth_pt�,i_ "---------------------` Cesspool: Distance from nearest well-----------------Distance from foundation.-__----------------Lining material__-_.___; ❑ -----------Depth------------------------------ -------------------- Privy; ---------- ------ Liquid Capacity gals. Size: Diameter---------------------- -- - . __ __._Distance from nearest building Privy: Distance from nearest well----------------------------------------- g ------------- -- ---------- ------- ❑ Distance to nearest lot line------------------- ------------------------------------------------ v 4 Remodeling and/or repairing (describe):_--- __--elh-1 -,- -t------�-------------------•-------1----•• ----- 7�� fl --------------------------------------- ---------------------------------------------- - --------------------------------- --------------------- ------------- ---- -------------------------------------------------------------------------------------------------------•----- ------------ 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)--- ----------------------------------------- - ct [Owner and/or Contractor] r ct - -.� --- ----- - Tttle (Plot plan, showing size o lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I !_ - --- ----------------- DATE_ = _P__"C-`' ------------------------------------ APPLICATION ACCEPTED REVIEWED BY-------------------------------- ------------------------- -------- --------------------------------------------------------------•-- DATE-------------------------------- --------------------------- BUILDINGPERMIT ISSUED---------------------------------- ----------------------------------- _ . . Alterations and/or recommends#onst---------- --- ------------ ------------- ------------------------- ------ --------------•--------------------------------------------------------------- !;e ----------------------- /------ ............................ _ ------- - _. - ___--____ _ ____.-___ __ �. __ ------------ ti ...._ � --------------------------------------------- / b FINAL INSPECTION BYt -------------------- Date--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California E5 9 REVIsCo a-59 3M 3-'63 F.P.tq. -