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FOR OFFICE USE: --------------------------------------------------------- 'APPLICATION FOR SANITATION PERMIT Permit No. ---- --------- ------------------ --- - - (Complete in Duplicate) T Date Issued �_ a c[ This Permit Ex� ires 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 compliances with County Ordinance No. 549. JOB ADD Rt SS AW LOCATIQ --5 jdd6W Idlu ----------------- .Owner's -- ------Owner's Nam --- -------- -- ---- - ---- --- Cr Phone-------------------- 'Address___._. G --------A...-^-- - ---c------------ -------------------------' -' - Phone----------------------------------- ------------- --- ------------------------------------------------------------------------- ,Contractor's •-••---•----------------------------,Contractor s Name--------- .............. ---- Installation will sery R i e 'Apantmenfi House❑' 'Com:mereial"❑ Trailer' Court❑- Motel ❑Other E] "`Number_.ofli.ving units __Number of bedrooms bathsLot size :_ _ ___________ __ ___.________________ Waier Supply: Public system E] Community system Elmber Private Depth t -------- ft Water Table _- __._ . Character of soil to a depth of 3 feet: Sand [-] Gravel F] Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dote---.___.._..,_..__.1 No ❑ New Construction: Yes ❑ No E] FHA/VA: Yes ❑ No El 1 TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within-200 feet.) Y - Septic Tank: Distance from nearest well---------------- Distance from foundation------------------Material------------------ -___._____________.__________- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-----•-------------------Capacity------------,---------- -�� Dispas Field: Distance from nearest well_._ d- _Distance from foundation---- d:_�_____.Distance to nearest lot line------ i Number of lines___------- ___....X _____Length of each line----_-.+'�'__Q__ _______________Width of trench----a„3��-_,----------- Ty' __..______._____.___ I Type of filter material______ {_ _}____Depth of filter material______� _`�_____Total length___ S __ __.____________________ � 1. Seepage Pit: Distance to nearest well---------------------Distance from foundation_...---------.-----.Distance to nearest lot line__________.____.- ❑ dumber of pits----------------------Lining material------•----------------Size: Diameter-----------•-----------Depth_J_.------.-------------------- r i Cesspool: Distance from nearest well----------- ---Distance- from foundation--------------------Lining material____..I..____.__-__-__-______-_.___. 1n i ❑ Size: Diameter-------- - -------- --------- ---_.Depth---------- ------'----------------- ------------- Liquid Capacity-.--J-----------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_--_--__-__________________________._. ❑ Distance to nearest lot line------------------------------------- 5,1 - Remodeling and/or rep iri g (des be):--------- ------------- --------- ------------------------------------------------ -- ------------ ---------- =----- ------------------ ---------------------- ---•----------------------------------------------------------------' --------------------------- ------s---------- � ' i --- ---- ------ ------------------------------------------------------------ ----------- --------------------=---------------------------------------•----------------------•-----•--•--- •----- --------------------------•----------------------------------- I I `hereby cert: at I hav _preps ed this application and that the work will be done in accordance with SantJoaquin County a -ordinances, Sfat - aws and'rules and regulations of the San Joaquin Local Health District. . y. .(Sigited) Y «-- -- :,- -- --------------------------------'------------------------------------•-- or Contractor]. E` By-- ------------------ -----` ...... i-------- ----- --' ---------------------------------------(Title)----------------------- ---------- ,.[Piot plan, sho ize of lot, location of sy em in.rela n to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------------------------------------------------------- DATE----,i ---------------- ---------------------------------- - - ----------------- (REVIEWED BY------k-- - ---------- ----------- ---------------------------------------------------------- DATE---------------- ----------- - - ------------------------- ,BUILDING PER ISSUED ------------#-------- ------------- --------- - DATE ._ ._ Alterations and/or recommendations:-- -------- -- ------------------------------------------------------------------------------------------------------------------------------- -, yrs i { k____________________ _________________________---------- ----_------------_----------------------------------r I------------------------------------ -- ----- `` -------- --- --------- ----------------------------------------------------------------------------------------- - ------------------------------- FINAL INSPECTION BY:.-- ��?-�!-•--- ` ------•----• Date ----- � C S f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoielton Are. ' ' 300 West Oak Street 124 Sycamore Street 205 West 9th Street i Stockton,California r- Lodi,California Manteca,California Tracy,California E5 51 REv16Ed B-59 3M 3-'63 V.p.QQ. ' ,