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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.-------------------------------------------------- ------------------------------------------ (Complete in Duplicate) Date issued ----------------------------------------------------- - This Permit Expires 1 Year From 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. JOB ADDRESS AND LOCATION--------------- ----_-__- __-___-_-_�___ S-----------1_0Z -___ Owner's Name-------- r •--i--------- ---•-••------------------------- ----- -------------- Phone-----•------------------------------ ------------- Address................... "" `_-` •`�"-— --- ,Contractor's Name----- ----� --- --------------------------------------------- Phone---632.E-� Installation will serve: Residence Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms __" _ Number of baths -tOL_ Lot size ._ /_`__.1 __ "_____________ Water. Supply: Public system ❑ Community system % Private ❑ Depth to Water Table ________ it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe a,, Hardpan ❑ Previous Application Made: (If yes,date-------------.------- New Construction: Yes 0 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well_ r-�_i_�__ r__Distance from foundation__./�_____.__.Matenal__.. __________- ❑ No. of compartments----------A-__._____.Size__X4 _5(!� `_,___Liquid depth------- .!. -------Capacity___1AS0d; _.__. Disposal Field: Distance from nearest well/104'4_-Distance from foundation__ .__ _ ..__-_.Distance to nearest lot 171 Number of lines----------- _ --....___Length of each line--------4?0- _._ Width of trench._______ Type of filter materiaL___,/�__ Depth of filter material___.___,l;r�y__._Total length___.____�e�_� � 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----------------- from foundation--------------------Lining material------------------------------------- Size: _.__..--------- -.-.-______.__Size: Diameter--------------------------------------De fh------------------------------- -- ---Liquid Capacity ----------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----.__-_-_-------__.________..___...___. ❑ Distance to nearest lot line-------------------------------------------------•----------------•-------------------------------------------------- •-------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------- ------------------------- -----------------------------------------------------------------------------•----------------------------------------------•----------------------------- ------------------------------------------------------------------ -------------------- ----------------------------------------------------------------•----------------------------------------------------------------------------------------------•-------------------------------------- . ------------------------------------ -----------------------------------------------------------------------------------------------------------•-- ---------------------------------• ! I 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. 4 (Signed)---------------�-- p4z�--------- ------ ----------------------------------- ----------------------------------(Owner and/or Contractor) By=---------G- -- ------ �►R r------- - ------------ ------- -----(Title)- -------- - (Plot plan, showing size o ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED —--------------------------------------------------------------------------- DATE------� __ rd REVIEWED BY--------------------- ----- --------------- -------------------- ------ DATE---------------- ------ BUILDING PERMIT ISSUED--- --------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------ -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------•------------------------------------------------------------------------ -------------------------------------- ---I--------------------------------------------------------------------- ---------- ------------------------------------ --- ------- ----------------------------------------------------------------------------------------------_---------------_---•---------------------------------- ------------------- ----------------------------------------------------------------------------------------------------------------•--- -----------------------------•------------------------------------------------ ------------------------- FINAL INSPECTfO Y:. � Date -_ --Date --------------------------- ----------------- N 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 a ES 9 REVISED 8-59 3M 3•'63 F.P.CC. 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