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FOR OFFICI,USE; 1�36P,,, ...................... ......... . -------------r4l--------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ... . .. --------------------------------------------------------- (Corn!,Oletv in Duplicate) _ ....... -------- --------------------I------------- ---------- This Perm'itzExpires 1 Year From Date issued Date.Issued Z_ 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 mad-e in compliance with County OrdinAnce No. 549. 0 JOB ADDRESS AND LOC3o j TION ----------- -- ------ .................................... Owner's Name ------ ------ -------- --------------- Phone -------------------------------------- T Address______________ ---------------------------------- ......-------------------------------------------I.................................... Contractor's Name----------c --- T3---------- -----•_•--------------••-;-----=-- ......... ------------------------ Phone...........------- ---------------- Installation will serve: Residence ®—Apartment House [j] Commercial El Trailer Court 0 Motel 1:1 Other El ::.Number of living units- j---- Number of bedrooms Number of baths Lot-size Water Supply: Public system El Community system E]�` P_,;vate []j-`bepth to Vater Table A/04. Character of soil to. a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam,o Clay Loam 0 Clay 0 Adobe ffHardpan [] Previous Application Made: (If yes,date---------------------) No New:Consfructio' n. Yes KrN-o [] PHA/VA: Yes E]. No IZI— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,public sewer is available within 200,feet.) Sept' -Tan Distance from nearest well__--------------Di stance from foundation---------------------Material No. of compartments---------------------------Size-----------------------------------Liquid clepth---_----------- ----Ca aci}y------------------------ Disposal Field: Distance from nearest well--------Distance from founclat'lo"n..30..........Distance to nearest lot lineL5--' . a ----------------------7-'- Number of lines----- trench--__.:;2 Type of filter mater-i-a-I_---- ---- ------------LIngth of each line-----41� _------_-----.Width of of'filt(;r 'Material---l--*----------Total length------ ---------------- 4 Seepage Pit, Distance to nearest well_/00----------Distance from fcjundafion./iP!Z1' ------Distance to nearest lot line-s.�_" Number of pits.----_/--------------Lining -----Size: Diameter-----tt__�----- ----Depth--- --------------- Cesspool: Distance from nearest well-------------- -Distance from foundation---------------------Lining material_--___----__-_-------.--_-----_-__.. ❑ g, Size: Diameter--------------------------------------De fh--------------i-------------------------------------Liquid ,S. 'k P Capacity----------------------------gals. Privy: Distance from nearest well----------------- ---------------—_1-------Distance from nearest b0cling----------------------------- .. ------------ E] Disf'an�ce-'to' nearest lot lin";--------- ---------------------------------- -----------------------------------------------------•----••----------- - Remodeling ----------1------------ Remodeling and/or repairing (describe):-------------------------- --------------------1-1...--------------------------------------I------------------------------------ -------------------------------------------7----------------------I----------------I-----------------11:--------------------------------------------------------------------------------- - $ �j --------- -------------------1-••----=- -------------------------------------- ----- -------------------- -------------- ----------------------------:---------w----------------- ]----•----------------------------------------------------------------- I -------------I----------------------------------------------------------------------------------- --------- --------------- ---- relation 0 fch� San a Vnj o ---------------------------- ----------------------- I:hereby certify-thaf I have prepared this P c 104:11nd that the work will be done in accordance with San Joaquin' County n eg ordinances, State laws,' and rules and regulat ns f h6 San Jo quin Local Health District. (Signed)--------------------------- - - - - ----------------- - --- - .......... -----------------------------------------------------------------------(Owner and/or Contractor) i By:----------------------- -------------------------------------------------(Title)------------ to wells, buildings, etc., can be placed on reverse side). vs (Plot plan, showing size of lot, lova ion o sys min FOR DEPARTMENT USE ONLY tl APPLICATION ACCEPTED BY_.- - --------- ------ ---- ---------------------------- DATE_..'I ---- ------------------- REVIEWEDBY-------------------------------------------------------------------I------- DATE -4------------------------------------------------ ----------- BUILDING PERMIT ISSUED--------------------------------------------------------------___-------------------------------.-. DATE Alterations and/or recommendations:--------------------------------- ------------- ---------------------------------------------------------------------------------------------------- ------- -- -----------------1.1�------------I____- — ---------- ------- -—---------------------------- ---------------_-...... ------- -- ---- ----- --------- __;__C...... -------------------- --------i�------------*--------- �_0--07-- 4? ------------ ------------ ---------------------------- ----------------------------- ,---------- ------ ....... --------------------------------------------------------------------------------------------------- Y -------------- ------- FINAL INSPECTION BY— ------------------ - -Date--------- SAN JOAQUINILOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 1.24 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9-9 REViSED 0.59 F.PXP.2M 6-60