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FOR OFFICE USE- ----------- ------------- SE:------------------------------------- -- --------------- --------------- APPLICATION FOR SANITATION PERMIT Permit No. f.7 1 (Complete in Duplicate) -------- ------------------------ 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 the work herein described. This application is made in compliance with County Ordinance No. 549. L o fl JOB ADDRESSD LOCATI N --�j_�-- _�4� __-A!x•S7_f�+-x„g__a? __`'4?'. tl..____. fJ-- ! R�'` .�-......-- Owner's Name--�'�?�'-r------- ---------------- ------ -- Phone.................................... Address ....-va3;7. . ........ ....... - Contractor's Name--------- ----- Phone .-.-.-.-.-.-.-.-.-.-.-.-.--..--..-.-.-.-.-.--..-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I__-_ Number of bedrooms 3-_-. Number of baths --- Lot size ..._.._ _ ._ -•--. _----•-.-.---_ Water Supply: Public system ❑ Community system ❑ Private Z"'Depth to 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 ❑ 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-----------_-�------ DisU ielcl: Distance from nearest well---.Ssi.---_____Distance from foundation...../P. ___...Distance to nearest lot line....._....... Number of lines----_..../-----------------------Length of each line........9Ll.---_---___-_.Width of trench_.. --- of filter material-------------------------Depth of filter material---------------------._Total length------------------------------------------ -V Seepage Pit: Distance to nearest well__--------------------Distance from 'foundation-------------------.Distance to nearest lot line----------------� ❑ Number of pits______________________Lining material--------------.--------Size: Diameter-----------------------Depth------._-.____--_---.-_--_._-_-__ `• Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____-------.---_-__-_.____________ zP ❑ Size: Diameter--------------------------------------Depth--------------------------------- --------------Liquid Capacity----------------------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------_--------------- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- ---- Z.. to Remodeling and/or repairing (describe) (2.,ole-o------------------------------------------------------------------------------------- --------............................... -------------------------------•-------------------•-----•---------------•--•-------------------------•-------------------------------- ------ -------------------------------------------------------------•---------------"''---------------•-------------------------••-------------------------------------------------------------••-------------------------------- - -------------------------- ---------•----------------------------------------------------------------------•----------------------•------------------------•---•------------------- --------------- 1 hereby certify that I have prepared this. application and that the work will be done in accordance with San Joaquin County 7 ordinances, State laws,6andLilocan egulations of +he San Joaquin Local Health District. (Signed)-------------------------- -- -------------------------------------------------------------------------{' and/or Contractor)By:•-•---------•--••-• . ---- ----- -----------------------(Title)-----------------------------------..--------- -- -------------- (Plot plan, showing size , +ioof system in rela+ion tow IIs, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATEQ'- ---- ----------- ----------------------- REVIEWEDBY-------------------------------- --------------------------------- ------ DATE-------------------------------............................. BUILDINGPERMIT ISSUED-------------------------------------------------------------—-------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------- ................. --------------------------------------------------------------------------------------------------------------------------------------- ---•-•--•---------------------------....---------------------------••-- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--- ------------------------------------------------------------------------ ----------------------------•---- ------------------------------------------------------•--------------------------------------------------- ---------------------------- . --------------------------------- ---- -------- r FINAL INSPECTION BYit �`�' ` _f --- ------------------- Date.---- '-3' �+T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.CD.