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FOR OFFICE USE: ------------------ ------------------------------------ - C� / __---------------------___--------------------- APPLICATION FOR SANITATION PERMIT Permit No. .-_ 7 ._._!__ . •C -- - - -- --------- ------------------------- (Complete in Duplicate)- q/r�'!�'�' - r ------------ This Permit Expires 1 Year From Date Issued g{,- Date Issued --- _!�_ i. 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. ot7-02-y_t/ `Fb (g 1E - k X-Av�s7-Ad. j,, A JOB ADDRESS AN LOCATION 4_4 Owner's __per_y •c�s , __ a�(r____ �[' _ OwnersName. ----- --------------------------------------------------------- ----- --------- Phone------------------------------ Address. .oma T ----------------- - -- •-- Contractor's Name------•---- ' `1��`` ' ". ... ...... Phone-...-------•---------------------- Installation will serve: Residence [Apartment House E] Commercial ❑ Trai€er Court [] Motel ❑ Other ❑ ' Number of living units: ...I_ Number of bedrooms;;,3-__ Number baths _2�Lof size ----------------------------------------------------------- D Supply: Public system ❑ Community system ❑ Private Depth t Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam_�Clay Loam ❑ Clay ❑ Adobe L] 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.) i Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material _________ ❑ No. of compartments--`±--------- ------------Size----------------------------_-Liquid depth--------------------------Capacity---------------------- Disposa .ielcl: Distance from nearest well--4k)---A_.._Distance from foundation---�!�-_-........Distance to nearest lot line__________.. Number of lines_____; _ Length of each line--- __ _ 9 ' a. Width of trench- - ------------------------ Type of filter material_-_ __ _�-_-___De th of filter material_____ i p 1-19---- Total length---- ---------------------------- Seepage Pit: Distance to nearest well------ ---------------Distance from foundation--------------------Distance to nearest lot line_________________ _b1 ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-------------.---- ----Depth--.------ --- ------ Cesspool: r Distance from nearest well-________________Distance from foundation--------------------Lining material----__._.__.--_--.__._____-_________ (� _ . ❑ Size: Diameter------------ -------- ------------------Depth----------------------------------------------------Liquid Capacity. ---------------.-----gals. 4 Privy: Distance•-from.nearest well-n----------------------------------------------Distance from nearest building------------------------------------------ El Distance to-nearest lot line_ -- - -------•-------- ----------------------------------------------- - Remodeling and/or repairing (describe ____________ ___ _ _ �� v y� ------------------------------------------ - L.c-rr----.,ex------�1-�- • z. - --- -------'----------�------- - - '�.� -�o-- -- - - -- ---"--------------------------- --------------------------------- r 'I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and,,rules and regulations of the San Joaquin Local Health District. (Signed)---------- --- - ----•---------- --------- --- - ------ - ----------------------------------------------------------------------------------- -----(Owner and/or Contractor) BY: ----- -- - ----- - ------------(Title)---------------- ---------------- - (Plot plan, showing size of lot, location of system in re ion to wells, buildings, efc., can be placed on reverse side). n FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... =rY.r REVIEWED BYDATE _' - ------------------------------------------------------------------- DATE------------------- BUILDING PERMIT ISSUED------------------------------------------------" ---------------------------------- DA•TE. �. Alterations and/or recommendations------------------- -- t ---------------------------------------------------•--------------------- -•----------------------- ----------------------------- ------------------------------------------------------------------•---------•-----------•-•- -------------------------------------------- ---------------------------------------------------------- ---------- ------ --------------------- - --------------------------------------------- ------- -------•------•---- --------------------------------------------- FINAL INSPECTION BY:.._.- ±------;--�--------------- Date--- --------------------- SAN 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 FCS 9 REVISED 8-59 3M 3-'63 F.p,CD.