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FOR OFFICE USE: - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .. ..-_: _ ._ ------------------------------------------ ------- (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. ©(( -- (V.-� n JOB ADDRESS AN LOCATION__ -•'Ytcrer _ _ _-_ of '- -- -- ( - --- __-_ __,f �(... L ^-f'� ,�tu Owner's Name ' ----- -------------- - -- Phone------------------------------------ Addres's li - ------------ ----7------------------- -- ---------------- ---------------........-------------------------------- - Contractor's Name---- -- ' -- � fz---------------------------------- --------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/_____ Number of bedrooms t�_ Number baths -_ Lot size _--_4---- ------ __________________ Water Supply: Public system El Community system El Private Depth f 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--------------------I 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 ank: Distance from nearest well__ '�L' Distance from foundation-----/.�.-�_.Material__-__ ✓L ---------- No. of compartments___ ----- Size__.._-_ - Liquid --------Capacity-/ Dis osal field: Distance from nearest well...40_.___Distance from foundation.__.fig__ ..... to nearest lot line__._____.... p r� �j Number of lines_____-_n- ____ __.- Length of each lin `_ ^__ G`Width of trench-sad'_`___ -- ------------ Type of filter material_-t_______Depth of filter material.... _.:__________Total length____�_�_!�'__________________________ Seepage Pit: Distance fo nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 171 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Deptf -------------------_------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------.__________-____________-_ ,❑ Size...Diamate'r-_....==° `- -__ M.Depth------------------------------ --------------------Liquid Capacity- ------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----------._-_-_--___________________-_-_. f ❑ Distance to nearest lot line------------------ ------------------------------------------------- ------------ - Remodeling and/or repairing {describe)_---_________________---____r___-------------------------------------------------------------------------------------------- ------.--`---------------- ----------F---------------------_---------------------------•----------------------------------------------------------------------------------------------------------'---------`---------- 1 hereby cerci t ''at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stafe aws, nd rules an reg tions of the San Joaquin Local Health District. (Signed)-------- ---- ------ - --------------------------------------------------------------------------------------- r and/or Contractor) -------- - ------------ -------------------------- --- Title (Plot plan, sho irfg size of lot, location of system in r lation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__-____. ter /7 �1 DATE--- '. 1' --------------------------- REVIEWEDBY-----IA"4 ------------------------------------ --------------------------------------------------------------------- DATE----------------- ------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- ---------- --------•--------------•-----------------------------------------------•------ ------------------------------------------------------------------------------------------------- --------•------------------------- --------------------------------- -------------- ---- •---------------------------------------------------------------------------------------------------------------------------•---------------------------------.-- -------------------------------------- -- - - ------------------------------- ------------------•----•-------------------------- -----••-•-------------------------------------- ---------------------------- J iCF't - — FINAL INSPECTION BY:---- Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3-'63 F.P.ED.