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u :FOR OFFICE USE: . � , � ----------------- �/ .APPLICATION FOR.SANITATION PERMIT Permit'N6 / ------------------------------------------- - ° --------------------------------------------------------- (Complete in Duplicate) Z L G --------------------------.........._..__..___.____.___ This Permit Expires'il Year From Date Issued Date Issued -__ ______________ T 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. -114 JOB ADDRESS AND LOC TION /�r i k... / ------------ ' Owner's Name------�/ - -------- - ----- ------- ----•-------------------------- Phone � �. Address-------�.�� --------•-1-------- � ------- Contractor's Name------------------------------------ - --------------------------=----------------- ••--•--- Phone----------------------------------- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑� Motel ❑ Other ❑ SS Number of living units: /---- Number of bedrooms _,�___ Number of baths __/_ Lot size __��___�.�________.__. Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table's-6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobejg Hardpan ❑ Previous Application Made: (If yes,date--------...e--------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: k (No septic tank or cesspool permitted if �Ubllil.cewer is available within 200 feet.)Septic Tank: Distance from nearest weil( __Distance from foundation_ZQ_-----------Material__ _...___________- ____..______ ' No. of compartments____OR_1______._____Size._J� s ..___-___Liquid depth_____�_.,__.___..___sCapacityli_Wd-_ + _ .........Distance to nearest lot lir; --------- 7K _______S_ Disposal Field: Distance from nearest weII�Z __.Distance from foundation. Length of each line__S0___1____��_____---Width of trench.-_-�y.__ _________________ Number of lines__________--___-_- g Type of filter mate riaL_J��_��___Dept h of.,filter,mate ria l__,ls�_____________Total length_---------------------gd-__________ OQ Seepage Pit: Distance to nearest well----------------------Dis#anee from foundation------------------.Distance to nearest lot line----------.-___._ W ❑ Number of pits----------------------Lining material-----------------------Size: Diameter.----------------------Depth------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------_Lining material------------------------------------- Size: Diameter-------------------------------------De th----•----- ' --------- -----------------Li Liquid Capacity ❑ p q --------------------------•-gals. . Privy: Distance from nearest well__._________._________________�__�___�._Distance from nearest,lauilding.-__________________________-______._._. d € ❑ Distance to nearest lot line--------------------------{-----------------------------------••--------------- -;------------------------------------------------------- 0 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, to laws, and rules and regulations of the San Joaquin Local Health District. s (Signed)____.PIM-1 (Owner and/or Contractor) ---------------------- -- ----- ------ - -- ------------- ---- - --- ------- '-- "'' -----------------------------------------Title (Plot plan, showing size of lot, location of system irlrg�ion fo�wells, buildings, etc., can be placed on reverse side). V i FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED -BY------L� ------------------------------------------------------------------ DATE------` Z ' ------------------------ -- REVIEWEDBY--------------------------------------------------- -----------------------------------------------------•-------------------- DATE--------------------------------------------•-------- ---- BUILDINGPERMIT ISSUED---------------------------------- ----------------------- -------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:----------------------------------------------------------------------------------------------•-------• -------------------------------------------------•--- ---------------------------•-----------------------•----------------- -------- --------------------------------------------------------------------- ----------------I---------------------------- --------- --------- ------------------ ---------------------------------:----------------------------- .......------------------------------------------------------------- ------------------------------------------------------------------------- - ---------------------------------------------- --------------------------------------------------------------------- ------------------------- FINAL INSPECTION ---------------------- Date...... ` Z -- - ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ' s CS 9 REVISED 8-59 3M 3-'63 F.P.CO.