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FQR OFFICE USE: (U r Permit No. ___.-.,,,............. �Z �� APPLICATION FOR SANITATION PERMIT r ------------------- ------------------- (Complete in Duplicate) Date ISsued �__L.�. --------------------------------------------------- ------- This Permit Ex- fres 1 'Year From Date Issued 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 LOCATIO * > _ _-. --------------------- -� -------------•--•---------------••--------------- Owner s Name-- ---s- a------ - --•--------•-----------------------•---------------------------------------- - Phone----------------------••----------- ---------• --------------------- Address------••- - - 1 - ------------------ ---- Contractor's Name-------------- - ---------------•-------- Phone..----•--•-•----•-_-------------- i Installation will serve: Residence lb___Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living amts: _____ Number of bedrooms ______ __ Number of baths __(____ Lot size ----.`S____.__-_-.I____...---------------------------- Water Supply: Public system �ommunity system El Private E] ' Depth to Water.Tableo— ft. 1 Character of sail to a depth of 3 feet: i Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8---Hardpan ❑ Previous Application Made: (If yes date--------------------). No.CT'_' New Construction: Yes.❑ No P!r FHA/VA: Yes ❑ No � i • 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-----------------Distance from foundation--------------------Mater-saL._--.________---.._____.._-.-.___.._____---_.- lo. of compartments-------------------------Size------------------------------Liquid depth--------------------------Capacity---------------------- dA�l Disposa Field Distance from nearest well_________________Distance from foundation___.___-__.__-_.----DiStanceto nearest lot line------------------ Number of lines------------------------------------Length of.each line------------------------------Width of trench----- ---------------------------- Type ---------------- -'-Type of filter material------------------------_Depth. of filter'material----____--:_____-,_,_:.Total length___._-._---______:______________---_______ 6 I Seep�ag/e ��t: to nealrest.wel ------ ---------Distance from foundation-_� ___-_____Distance to nearest lot line----------------- Distance ` Number of pits _ __..____ ___-_Lining materiaL_� o- -�?__.Size: Diameter_____- : .-._ _Depth----- ,}_ ____ _________ Cesspool: Mance from,In well________________Distance from foundation.-.-_._..__-__`__...Lining material...:---_---______-------------------- ❑ Size: Diameter- ----------------------------- ---Depth--------- ------------------ - --------------Liquid Capacity-- ------------ gals. Privy: Distance from,larest well-------------------------------------------------Distance from nearest building------------------------------------------A ❑ Distance to nearest lot line------------------------------------------------------- --------•-------------- ---------------------------------------- -------- ------- L Remodeling and/or repairing (des!l-- ribe)=-------- ------------------------------------------------------------------------------------------------•-----------•-•------------------------•----------. 1 ------------------------------------------------------------------ ------------------------------------------------------- ------------------- ----------------------- = 1 -- ----------•--------- -•----------------------- t ------------------------------------------------ --------- ---- ------- . --- --- ---- ---- ----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulatio of the San Joaquin Local Health District. (Signed) { __-______________________-__________--.____.[Owner and/or Contractor --------- -- -------------------- -- ---- ----------------- ------------------------------ Plot plan, showing size of lot, Iota on of system in Tltle By:-------------- -- ------------ -- - --------------------------------- -----------------------[ ' ------------------------------------------ - - ---------------- [ p g 1 y elation to wells, buildings, etc., can be placed on reverse side]. i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- --------------------- - DATE -------- / < ...-. - REVIEWED BY-------------------------------------- -----------------=--------- - - - - ------------- DATE------------------------------------------------------.---- BUILDING.PERMIT ISSUED-------==` =---------------------=---------------------- - ------ ------ DATE----------------- 7------------------------rL-------------- -----u_ -- ----- _I I Alterations and/or r eco` dations___________ _ _/_�_-. --- ----. -- -- r�.. r ----------------------- - i== � -----------------------` ` -- = -------------- --------------- ----------------- r---------------------=----------------------------------------------------------------------------------------------------------------------------- ------------ FINAL INSPECTION BY: � Date-- ------7 ------ ' ��..�r- ----- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nexellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISER S-S9 3M 3-'63 F.P.M3.