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} /� �4 33 61 APPLICATION FOR SANITATION PERMIT Permit No. -------------------- (Complete in Duplicate) 0 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 and install thew rk herein described. This application is made in compliance with County Ordinance No: 549 '" "mm � A1 ' JOB ADDRESS CATION-------- � �-------- A - - ------------------ -----Z:��-- ----- ---------------------------- Owner's Name----------- iMM C07-T— --------- ---------------------------------------Phone-------------------------------- Address - --------- Address--------------------- _ ...------- --- ...--._...---...--- Contractor's Name'� -------------- - rA � j._. Phone = ..._------------ -----•------ Installation will serve: ResidenceA'arfinent'House ❑ Commercial ❑ Trailer'-Court-❑- Mofil ❑ "Other ❑ Number of living units: ___�____ umber of bedrooms _ -'Number of baths I_____ Lot size _--'`�______x____----- ______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table __.___ ft. Character of soil to a depth of 3 feet: Sand • Gravel E] Sandy Loam Clay Loam•❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes Q Ido ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T nkat' Distance from nearest well----------------Distance from foundation--------------------Material--------------------------- _____________.____- No. of compartments--------------------------Size-----------------;---------- ---Liquid depth-- ------ ------ ------- Capacify-�'- .------- osal lel Distance from nearest well ell--��--..._Distance from foundati n___ � t ��_________:Distence to nearest lo; line � r , Number of lines______o _________ _.,_Length of each line_____-_ _ .tr_._____:__Width of`trend___ _________________________ }- Type of filter material 61e epth of filter material____ 9____.....'---Total length_______.Q______________________________ 11 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___:________.._- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------i------------------- • a Cesspool: Distance from nearest well-----------------Distance from foundation-------------'_____.Lining material---------.-------------_--_----_______ El Size: Diameter------------------------------------_De th_--------------- --------Liquid Capacity gals.,, Privy: Distance frosn.nearest well------------------------------------------------- from'�nearest building-----.-.-__--------___________.____.-__... ❑ Distance to nearest lot line------ -------------------------------------------- - ---- q� --------------•-------- --------- Remodeling. an /or .eparing (describe) - �} ,- ----- - -`�-•• --------- I---- -------- - --- - --- ------ --- - --- ------ ----- ----------------- --------- ----------+----------------- -- ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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, ws, and rules and regulations of the San Joaquin Local Health District. 4 (Signed)____ (Owner and/or Contractor) ----------------------------- -- ------------------ By:---------------- (Title} ----------- --------------------------------------------------------------- ------- --- --- --------..._........... ' (Plot plan, showing size of-lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- - ---I,? ------------- -------------- -------------------------- DATE------- ----- - REViEWED BY DATE -- -y —-i BUILDING PERMIT ISSUED----------------------------- ---------------------------------------------------------------- DA•TE------------------------------------------------------------ Al#erations and/or recommendations:----------------------------- ---------------- ------ --------------------------- ----------------------------- ------------------------------------------- ------------- �.v - _ - ----- - ----------- .....tea ----- , ---------------------- / — ��-� �•�� FINAL INSPECTION... �f---------I------------------------------------- Date---------------------------- ------------ ' -- - ------------------------ f SAN,JOAQUIN ---------------------- SAN,JOAQUIN LOCAL HEALTH DISTRICT.- 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street - Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 P.P.Co.