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FOR OFFICE USE: -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. y- - - ------------------------------------------------- (Complete in Duplicate) Date Issued--------------------------------------------------------- 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 compliance with County Ordinance No. 549.r._..�- w '-60 1 1 JOB ADDRESS AND LOCATI - -------- • ------ - --••-�'! - - --- -- - ----------- -------- /� Owner's Name---- l -•----- ------- ----- --- --------- Phone------------------------------------ Address--------- ---•••-----------------------Address-------- •-•.- d -------- Contractor's Name--------- - -- ----------------------------- Phone---------------------------------- Installation will serve: Residence Apartme House ❑ Commercial ❑ Trailer Court ❑ Mo�el ❑ Other ❑ Number of livingunits: _ - Number of bedrooms _ __ �-� 1--- ,Y-- Number f baths of size _ .. Water Supply: Public system ❑ Community system ❑ Private [Depth 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 ❑ l 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---------------------------- ---Liquid depth----------- --------------Capacity----------------------- Dispos Field: Distance from nearestwell-__-sc7--1 Distance from foundation_---__�d_.._-Distance to nearest lot line---s________ Number of lines__________ __ _ Length of each line____----6.e___._ ___.Width of trench______ r. -- Type of filter material;___ _ _;_{1:�-E_-_Depth of filter material___--�_�-__-_---Total length______ _: Seepage Pit: Distance to nearest wei!----------------------Distance from foundation--------------------Distance to nearest lot line_______.___--__-__ [] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- G Cesspool: Distance from nearest well_________________Distance from foundation---.---------------.Lining material__-_____--_-__________________"______ ❑ Size: Diameter--------------------------- ----------Depth--------- --------------------- -- ----------------Liquid Capacity- - ------------------------gals, S]rl. Privy: Distance from nearest well-----__.----------------------------------------Distance from nearest building--------------------------------.-------_. 6- ❑El Distance to nearest lot line-------- ------------ -.------------------------------------------------------------------------------------------------ ------ Remodeling and/or repairing (describe):-------- ----- ------- ------------- --------------------------------•------------------------------------------------------------------------------ --------------- ------- --- ----- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby ce y that have prepared this application and that the work will be done in accordance with San Joaquin County 9+ ordinances, Stat laws, n rules and regulations ofRfa aquin'Local Health District.(Signed)-------------- ----- ---- -- -----•--------- - - �" or Contractor) tie---------- ------------�---- ---------------- --------- BY= ) (Plot plan, showing size of lot, Iota ton of system in relation to wells, buildings, tc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------------------------------------=-��__ --)EY�C--•-- DATE-------- .7-7-97'-4------ ----------------- REVIEWEDBY----------------------------------------- --------------------------------------- ------------------------------•------------ DATE- BUILDINGPERMIT ISSUED-------------------------------------------------------------- -------------------------------- DATE---------------------•-------------- ----------------------- Alterationsand/or recommendations---------------------------------- ----------- ------------------------------------------------- -•------------------------------=------------------------------ -------------------------------•--------------------------------------------- --------------- -- ------------ -----------------------•--------------- ------ -------------------------------•-------------------------------- -----•----------------------------------------------- ------------------------------------------------------------------------------------------------------------------ ---------------------------------------------•------_ --------------------------------------------------------------------------- ---- - ----------------------------- -_------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY---------------------- - /C._l_L Date-------------- -- -------- ............- - SAN JOAQUIN LOCAL HEALTH DISTRICT \ 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 0-59 3M 3•'63 F.P.CC.