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FOR OFFICE USE: :---------------- -- ------------------ - 3 APPLICATION FOR SANITATION PERMIT Permit No. ___l _ ------------------------------------ ------ ----------- - (Complete in Duplicate) / ___.__. This Permit Expires 1 Year From Date Issued Date Issued ._______ Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal{ the work herein described. This application is made in compliance with County Ordinance No. 549. "Q 0-5-a o<P0 --ZZ f Q7'�S'['3 A-) . c.c1E.s7`"'L�t,J ' j l JOB ADDRESS AND LOCATION---��f ' -------- Owner's Name------------ ---- - ---------------------------------------- Phone------------------------------------ Address------------------- --------•-•--------•-••------------Address---------------•---• J ------------------------------- ------------------- Contractor's Name...... ----------------------•--•-----------------•-•--------------------------------------------------------------------------------- Phone..--------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial Ro Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ________ Number of baths -L____ Lot size ---------------------------- Water Supply: Public system ❑ Community system ❑ Private L J Depth to Water Table d_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�0 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__.Go'.--.-__Distancet�from foundation_-/O-------------Material-Wt-04. -------------- ------ WNo. of compartments....;--.....------------Size3l___[_t--- --------------Liquid depth--#--------------------Capacity_? ________--.___ Disposal Field: Distance from nearest well---90........Distance from foundation_115--------------Distance to nearest lot line__1_P'-------- ® Number of lines---- -----------------------------Length of each line-------7.5-----------------Width of trench_. `'Y_..........-............ Type of filter materia• sfi _-Depth of filter material_-__/z'-------------Total length__2r__________ ______________________ Pit: Distance to nearest well--/"_'-----------Distance from foundation----J_9----------Distance to nearest lot line6a'-------- [ v Number of, O ---.1......Lining material N" . -----.Size: Diameter.___ �--------------Depth---1_ `'--'- 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-------------------------------- ------------------------------------- -------------•----------------------------------------------------- Q Remodelingand/or repairing (describe):------- -------------------------------------------•-•---------------------------------------------- -----------------------------------------------,r, ---------•-------------•-•-------------------------------------------- ----•-------------------------------------------------------------------------------------------------------------------------------------------------- I ------------------------------------ -----------------------------------------------------------------------------------------•-----------•------------------------------------------------------------------------------_ -----------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- I hereby certify that I have prepared this application and that the work wiil be done in accordance with San Joaquin County ordinances, to laws, and rules and regulations of San Joaquin Local Health District. Iliv fit (Signed)- ------ -------- -- - -------------------------------- ---------- -------------------(Owner and/or Contractor) G By:---------------------------------------------'--=---------- ------------------------------------- --------------=t-----��----{Title)------�•--�---•--------- ------ ..._. ------�M ,. (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 APPLICATIONACCEPTED ------------------------------------------------------------ DATE--- -y---------------------------------------- REVIEWEDBY------------------------------- -------- ---- ---------------- ---------------- ---------------------------------------------- DATE----------------------------------------- --------- BUILDINGPERMIT ISSUED------------------------ ----------------------------------------- ---------------------------------- DATE--------------------------------------------------------- Alterationsand/or recommendations-------------------------- ----------------------------------------------------------------------------•-----•-------•-----•-----------•-------------------- ----------------------------------------------------------.------------------------------------------------------------------------------------------------.-------------------------------------•------------------------- ------------------------------ ------------------------------------------------------ -- ---------------------------------------------------------------------- ---------------------- ---------------------------------- FINAL INSPECTION B ---------------------- Date.... �� b7--.--- --- ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Are. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California E5 9 REVISED B-59 3M 3-'63 F.P.CD. w: