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FOR OFFICE USE: ----------------------------- ------------------------ 1.14;1 APPLICATION FOR SANITATION PERMIT Permit No./ ---------- --------- ---- -------- . . --------------------- -------------------- - ----------- (Complete in Duplicate) I /. ' 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 c mplianc.e.with County Ordinance No. 549. 3rl. Hr - tf�i4- !2 ';�/ - - pal-- [?o,-.3 JOB ADDRESS AND LOCATION--/�-'- vim Z ¢ x`' a x Owner's Name-- - � --- -- - --------- ..------------------------- - ------ j - -------------------------------------------- Phone------------------------------------ Address Address--------- -- -- ------- - -----------------�: .--------- -------- ------ ---- --------.-.----•-•- Contractor's Name_.- ., t`` -------------------••---------------------- Phone...-----------------------..------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --:�--- Number of bedrooms _3--- Number o baths ---.-_ Lot size -- �- -------- ------------------------ ------ Supply: Public system ❑ Community system ❑ Private �pth t Water Table --___._ ft. i. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 7clay 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-----------•---------- ' / f Dispos Field: Distance from nearest well---�� --_---Distance from foundation-----�0-------.Distance to nearest lot line-�----.----- V Number of lines-------------/----------------------Length of each line------`eq_ -----------Width of trench.-_-- - ---------------------- Type of filter mater.ial-------�-t-------Depth of filter material--__. -f.......... .. Total length-----/-DG--_--.-_------------------ Seepage Pit: Distance to nearest well---------------------- 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---------------------------------:_' - n� ❑ ':a Size: Diameter------- -----------------------------Depth-------------------- -------------------------------Liquid Capacity_. ----------------------- gals. ^'•` - -Distance from nearest building Privy: t Distance from nearest well g ❑ DiY tancie.to nearest lot line---------------------------------------------------------------------------------------------------------------------------- ------- Remodelingand/or rewiring (describe):----- '=-------- --------------------------------•---------------•--•----------------------------------•-•-•-•-•---------------------------•---- ------------------------------------ `--------------_----------------- . # ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 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. -------•----------------- --- pd/or Contractor) (Signed)--- B (Title)- k (Plot plan, showing size-of.lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR'DEPARTMENT'USE,ONLY APPLICATION ACCEPTED BY---- - DATE-- �" �-- ------ --------------------- ----- - ------------------------------------------------------- ----------- -------- ------------------------ REVIEWEDBY----------------------IZ,/I�-1.�------------------------ ------------ ---------------------------- ---------------- DATE --- --7�--'-�4 ----------BUILDING PERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE--------- --------------------------------------------------- Alterationsand/or recommendations:------- --------------------- ------- -------------------- ------------------------------------------------------------------------------------------r---------- i. ---------------------------••-------------------------------------------------------------------------------------------------- i� --------------------------------- -- ------•-------------------- --------------------- ----------------------------- ---------•---------------------------------------- - ----------------------------------------- FINAL INSPECTION BY:-- -�YY—'�1//�---------------- Date---.----.--------------- i ------------------------------------------- -------- - I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California 4odi,California Manteca,California Tracy,California ES. 9 REVISED B-59 31A 3•'63 F.P.CO- k