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'DR OFFICE USE: ------- ------ APPLICATION FOR SANITATION PERMIT Permit No.--------------------------------------- .. .,7.1._ ---------- - - --- ---- ------ .. : Date Issued Z��_ _ (Complete in Duplicate) 7/ ---------------------------------- ----- This Permit Expires ] Year From Date Issued - ! Application .is hereby made to the San#Joaquin Local Health District for a ermit to construct and ir�,stall�the work herein This application is made in compliance with County Ordinance No. 549 f; pa �r .�� �p� JOB ADDRESS AND LOCATION--Its-1- - -- =,X �`�-�» --------- Owner's Name_-_ _ --- -- --- - ----- - ----. - -- ---�--- , ----------------- Phone---------------b S: ------------ .. . c --- `r-'.e- ----------------••------------ ----Address-----.�Q ------ Contractor's Name------ ---- --------- - - ----- ------- -- ---- -- ------------------------ ----------------- --- Phone......... 7- ---------- Installation will serve: Residence In Apartment House ❑ Commercial ❑ Trailer curt ❑ Motel ❑ Other ❑ Number of living units: _:_:__.Number of bedrooms _ ter__ Num��Depth baths _-___-_- Lot size ____ __ r�------------------------------------ Water _______________ __________________ Water Supply: Public system ❑ Community system ❑ Private 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_ 4_-__-------_) :No ❑ c 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-------------------------I-__________-__---____-- ❑ No. of compartments _Size -------------- ----------Liquid depth--------------- -•--------Capacity-----------=- 1 01 ------ I Dispos Field: Distance from nearest well--- .��.__Distance from foundation-----/.A?________Distance to nearest Iot,°line____' Number of lines_____'__ ---- --- ----------}Length of each line3f__ _ _Width of trench.-____- .-�_------------------- Iq Type..of filter material__ --------;!Depth of filter material-------/ ........Total length-------/;Fp-----_--______________ r �� , Distance to nearest well_-___f_k�__"__-�Qistance from foundation_______ ----.Dlstan to nearest lot'line____�____-_- G Linin material__,4- �-:_. Size: i aaae�her ____-____-_ 0 ❑ ''Number�of pits I 9 i c `rX Depth -$ OW Cesspool: Distance,from,nearest well___________--'!Distance from foundation--------------------Lining material--------_-__---_-------__-__________-. ,. t ❑ Size: Diameter.`--------------------- ---------'- th- Liquid Capacity----------------------------gals. w. Privy: Distance from nearest_weIL:R_�-Y--------------------- --------------Distance from nearest building__________--_----_-____-_--_-- _---- _ . -. G ❑ Distance to nearestrLot-lin4e----- ---------=------------)--------------------------------------------------------------------------------------------•--------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------ -------------------------------------------------------------------- --------- -------------------t- ----- ------------------------- --------------------------------=-----------------------------------•--------------•-•-------------------------------------•-•--------------------------- ---------------------------------------- 9. ------------------------------------------- = --•--------------------------------------•-------------• ---------------------------------------------------------------------------------- ----------------.--- -------- 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)----------- --- - ---- ------ ------------------------------ -------------------------------------------------( ------L'or Contractor) 1 _ Sy:------- `-------- -- ------- --------------------------------(Title)------ -- --------- -------- ----------- --- ------------------- -(Plo+ --- --------- -(Plo+ plan, showing size of,lot._location.of sys em..in relatio to-wells, buildings' etc., can.be.placed on reverse side). FOR DEPARTMENT USE ONLY rr�� APPLICATION ACCEPTED BY-- - ---- -- -------- ----------------------------------------------------- DATE---7� `-`---------- ------------- - - REVIEWEDBY----------------------------------------------------=------------- ------ DATE-------------------=--------------------------------------- BUILDINGPERMIT ISSUED------------------------------ ---------------------------------------------------------------------- DATE-----=------------------------------------------------------- Alterations and/or recommend a+ions:----1 ------ ----------- --------Y-- ---------------------------------------------------------------------------------------- -------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- FINAL INSPECTION BY: ---- - ----------------------------- Dat e...... ------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. r 300 West Oak Street 124 Sycomore.Street. - -205 West 9th-Street�� Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 0-59 3M 3-'63 F.P.CM a t