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----------- ---------------- `> ------ APPLICATION FOR SANITATION PERMIT Permit No. .__ _-` ` _, � T = ----- ---.. LL I (Complete in Duplicate) ------------------------ ---------------- ---- --- ,This Permit Ex fres 1 Year From bate Issued Date Issued _l_^._ `f' `� 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 Vo 549 JOB ADDRESS AND LOCATIO _-. -/ Owner's Name------ { l�--L------------------------------—T y ------------------•------------------------- --- --------------- --• - - •- -• - -- - ---•--• --- ---... Phone---------... --------------- -------------------------------------------- -----------------------------------------------------•-- t -----•-------------•----•-----•------•----•-•---------------------------------•------•--•---•-------- ••-----•---------------------- ----- - ------- -- Contractor's Name__ -_ - ----- --�--------•-- --- --- --•-------- Phone-----••----- - ------------------------------- installation will serve: Residence ®�partment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ Number of living units: -1----- Number of bedrooms _2, Number of baths ------- Lot size ._�4 Wafer Supply: Public system ❑ Community system ❑ Private Depth to Water Table __46P ft. Character of sail to a depth of 3 feet:' Sand ❑ Gravel ❑ Sand Loam E] Clay Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date_____._._---_ ____) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No E�' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank4or cesspool permitted if public sewer is available within 200 feet.) Sept' Anka r Distance from nearest well_________________Distance from foundation______ Material_.. ............... No. of compartments_ Size--------------------------------Liquid depth Capacity-- ---- -------------------- Dis Distance from nearest well-- d-r / .__Distance from foundationk r_-_-- Distance to nearest lot liner_________________ Number of lines_______ _________________Length of each line__�_�_-._--_-______._.Width of trench_ -44--------------- Type of filter material�GGIC-- -•- -•- _ f_ -___Depth of filter material_�g_..............Total length___._�----------------- ---------------- Seepage it: Distance to nearest well_____.______!> __Distant m f undation___I�__________, istance to nearest to Line--- Number of pits------- ________ Linin material___./_�_-A__ . -. _ Size: Diamefer-__. _ --- 9 __Size: 42_- ----------- 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):-------------__- -_____ ----------- -- ----- -------------------------------------- --------------------------------------------------------------------- ------------- I hereby certify that I have prepared this application nd that the work will be done in accordance with San Joaquin County ordinances, State Daws, and rules and regulations of fhe artJoaquin Local Health District. (Signed)----------•-------------------------------------------- --------------------- -- ----------------- ----------------------------------------------- ------(Owner and/or Contractor) - - -- 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------- �------- -----------------�—- - -----1--11f -- - -------- ------------ -------------- - DATE-- REVIEWED BY_ _,k DATE BUILDING PERMIT ISSUED-------------------- ----------- --------------------------- ---- ------------------------ _ --------------------- --- ----------- . DATE--------------- Alterations and/or recommendations------- ---- - -- -z: ,nom_ . -------- ---------------------------------- — --•-------- r -�.� -- � - L=s� P --- -- c -- --- - ------------ - _ - � �L- -t•-.� ff-r _________.______________________ ______ L_r- -------------------------------------------_---------- -------------- FINAL INSPECTION BY..... ---. ._ -- t _� � - i - ----------------------- Date = --�-�---- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haietton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.RCD.