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FOR OFFICE USE: ' '- -----__---- APPLICATION FOR SANITATION PERMIT Permit No. ._� �� .��:. ---- - ----- ----- ------ ------------------------------------------ (Complete in Duplicate) t G�CJ 0 ------------------------------ This Permit Expires I 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. - •--•-----------------------------•-----------••-- JOB ADDRESS AND LOCATI N---9"�-�/------ -- --------- - -�-��------------------.-...--------- Owner's Name ----- --•-- ---- --------•--------------•----• ------------------------------ - Phone. b ------•-••- Address------7_-�� -• ---- r•-•---- - -- ----------------------------------------•-•---------------•------- -------------------------------------------- rContractor's Names r f Phone Installation will serve: Residence Iq'�A_partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ t i Number of living units: --- Number of bedrooms ---Y.- Number of baths ...I-_ Lot size Z ��...................."-._-.---"-_. Water Supply: Public.system M-1tommunity system ❑ Private ❑ Depth to Water Table©_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made:' (If yes,date----- "----""----) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ff�-- 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- -t_Distance from foundationla.-.�-._...-_Material--- ------------- ] J- / �� th- y "_.--------"Capacity. °�No. of compartments----� v _ depI Disposal Field: Distance from nearest well.._Distance from foundation.-ZO-----------Distance to nearest lot line..��...... Number of lines-----------/-------------- Length of each line--------- .............Width of trench------- q---------.---. Type of filter material-_ � _ -- Depth of filter material--- ----------Total length--------------Q--------------------- X7_1 Seepage Pit: Distance to nearest well------- --------------Distance from foundation--------------------Distance to nearest lot line----------------- 4 ❑ Number of pits----------------------Lining material----------.------------Size: Diameter-----_------------..---.Depth---------------------.----.---... Cesspool: Distance from nearest well-----------------Distance from foundation.-------------.-.--.Lining material---.-----------------_----_-----.-... ❑ Size. Diameter--------------------------------------Depth---"---------------------------- -------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----._----_--_---.•---.-•------.-------. ' ❑ Distance to nearest lot line--=------------------------=------------------------------------------ ----------------------------•---------------------------------------- . Remodeling and/or repairing (describe):------- t ------- ----- --- ------------ ' :....q.1 ------------___...-•------------------------------------ -----------------------•----•-•-----•--------------------------.------------------------------------------------------------------------------------------------------------.-------•----.----•-----.-----.----------------- --------------------------•---------------"----------------•-----•-----------------------------------------------•---------•------------------------------------------------.--------------------------------------------- ------------------------------------------------------------------------------------------•-------• �--------------------------------------•-------. ------------------------------------------------------------------- - I hereby certify that i hav prepared this application and that the work"will be done in accordance with San Joaquin County ordinances, State laws, r s and regulations of the San Joaquin Local Health District. (Signed)------- -------- -- -•-- ------ =-------------------------------------(Owner and/or Contractor) By:- --- - -- By:- (Title) ---------- --------....... - -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-.- -."_ - ----------------------------------------------------------------------------- DATE--------------/�g � l REVIEWEDBY -------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------- •-•---•-- ----------------------------------------------------------------------•-••- DATE------------------------------------------------------------- Alterafjonand/or recommendations:-_--------- ----- -. --••---------- j ------------------------------------ ------- �" _ '3 -- ---hq-i/ '�=�---•---• r = f -t ............ �,/el---------- r ----------xwe ----------- ----------- . -------- 4'..'&- - r ------------------------------------------------------------------------------------------------------------------------------- 4p FINAL INSPECTION BY-.--.' trt ! Date. yt SAN ' Ys JOAQUIN LOCAL HEALTH DISTRICT � 130 Soufh American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California II ES-9 REVISED 9.59 r.P,Cn.YM 6-60 -