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FOR OFFICE USE- ------------------- SE:---------------- - 13 I APPLICATION FOR SANITATION PERMIT Permit No. .... ........../.. --------------------------------------------- ------------ (Complete in Duplicate) , ="" " This Pefmit Expires 1 Year From Date"' " Issued . ,.Date Issued -_--- -.-••--- 1. Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein descrbed. This application is made in compliance with Coun dinance No. 549. ----------------------------- JOB ADDRESS AND LOCATION-- Phone Owner's Name -----/ --------------------------------------------- t i Address------------------•----- = ...... -----------=----•------------------ ----------- -------------------------------------------------------=----..........._... Contractor's Name -- hone {�" .... P Residence Aar meet House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Installation well serve [� p Number of living units: Number of bedrooms "_Number of baths -___.l_ Lot size -------•--------•-•--- -----•-- Water Supply: Public system ❑�ommuriity system ❑ Private ❑ Depth to Water Table ..------ ft. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel [j Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe iardpan C] Previous Application Made: (If yes,date___-________________) No New Construction: Yes [[ Flo ❑ FHA/VA: Yes E] No OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) Seaic- nk: Distance from nearest well_________________Distance from foundation-------------------.Material..-------_------------------------------------- . No. of compartments------------- `----------Size__.--------------------•-------Liquid depth------- l- ------------.Capacity.....--------.--------- Disp Field. Distance from nearest wel _________________Distance from foundation-------------------- to nearest lot line----------------- i Number of lines --- --:-------Length of each line------------------=-----------Width of french-------------- Type of filter materiial-------------------------Depth of filter material------------------"---._Total length-----------------_----------------`--•-- v Seepage rt: Distance to neaprest well from foundation__ �__----_=_.Distance yo nearest lot line_______________ Number of pits/."{ -------•------Lining material �.C. - ----Size: D'iameter___•-- -- -----..Depth-------""-- -------------- Cesspool: -------- Cesspool: Distance from nearest well-----------------Distance from foundation----______-___y_--.Lining materia l____.______.___________________._____ Size: Diameter-------------------------------------Depth-------------------------------------- ------ '----Liquid Capacity-------------------- = gals; I ____--__Distance from nearest building --------------- Privy:, Distance from nearest well 9 Distance to nearest lot line------------• -------- -- ---------•--•---•--•--•-------------------•--•--------•--------••-=------ -----•------ Remodeling and/or repairing (describe).:--------------------------------• ----------------- f e ------------------------------------------------------------•---- I. ' ------------------------------- ------------------------ ------ q ill I hereby certify'tha+ I have prepared this application and that the work will`be done in accordance with San Joaquin County ordinances, State laws,'and rules an; .re lations .of the.San Joaquin Local Health District. 3 --------------------------------------(Owner and/or Contractor) } ----------------------------------------- = (Signed)----------- --------- --- - -------- --- --------------------------------------------------------- --- --- - BY: --- ------------ (Title) (Plot plan, showing size:o of, location of system in relation to wells, buildings, etc., can be placed on reverse side]. r R FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- •--"- -- -tip-�--=----"---L-4= JDATE REVIEWEDBY-------------------------- ----- ----------------------------------------------------------------------- ------ DATE--------------- ------------------------------------- BUILDINGPERMIT ISSUED---•................F----------------------------------------—----------------------------=-------- DATE------------------------------ ----------------------------- Alterations and/or recommendations:------------- ----- -----•---------------••-------•-•---------...--------•-----••-------------------• ------------------------ --------•--------• --------- ------•--------------- -------•--"------------•-----"---•----•-•---------•-----------•--- - ---=------•------•---• ---------- ------------------------------------------- i i ----------------------------------- -------- --------- -------------------------- - , F ______________________________________________________________________________________________________-------_-----------------_ Date---------------------�-=- &-Z——----------- ------ FINAL INSPECTION BY: ----. ____ - - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E6-9 REVI6E0 8.59 F.P.CO.2M 6-60