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f F R 'FACE USE: " & ---- ' - - ---------- .. - z � ------- ----- ---------- - ______ APPLICATION,- FOR SANITATION PERMIT Permit No. ..... -------------------------- - --------- (Complete in Duplicate) ------------------ Date Issued --------------------------------------- ----- This Permit Expires 1 Year From Date Issued " Application is hereby made to the San Joaquin Local Healfh 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 L CATION..- -- ------------." �_ . : Owner's Name .. ----- Phone '•"-•• ..........------------• --------------------------------------------------- ---- ---••---- Address ---' =... Contractors Name----- ------------ -------------- ------- --------------•- ----- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ "_ Number of bedrooms _S Number of baths A'—.. Lotsize �i _ Water Supply: Public system ❑ Community system ❑ Private 2--"Depth to.-Water Table ,4 f. Character of soil to a depth of 3 feet:I Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: (If yes,date----------- -------) No 22,0"New_1Construction. Yes ❑ No ) FHA/VA: Yes 2?"'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: F (No septic tank or cesspool permitted if public sewer is'available within 200 feet.) Septic,Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material ."=----_--__-_--------------------------------- No. .----_------_--------.No. of compartments-=-------------------- Size-----------------------------,---Liquid depth--.-----------------------Capacity----------------- Dis osaL.Fi Id Distance from nearest well ---."Distance from foundation_" -- p � ". ""�"-_-__--.Distance to nearest lot line""�"__"""_ Number of lines--i-""f-"-- Len th of each line_" ! _ __ ..g �-.___._- Width of trench-�.-____"_" Type of filter material":/= - - De.pth of,filter mater Total length----a�'t_�__-_-"-------_-_-_---__." r I Seepage Pit:. Distance to nearest.well-_ Distance ffoundation--__49;*9. Di tante to nearest lot line- ----- %a_ """. ,tai y Number of pits------/............Lining material"" �/""-Size: Diameter---- -------"_DepfhOOV A—.__ ,E_1_�,e._ Csspo Distance from nearest well----------------- from foundation-------------_-----.Lining material-----_-._---_---.--.----.--"------__. ❑ Size: Diameter-.- t------- -------------Depth----------------------------------------=----------Liquid Capacity------=--------------------gals. 0 Priv Distance from nearest well"______________".-.------_-----------..---------,Distance from nearest building❑ Distance to nearest lot line-------------------" �� Q Remodeling and/or repairing (describe):-----------------aG<G �%�-�----- --------------------- ------------------------------------------------------------------------- r -- ------------------------------------------ -------------------------------------------------------------------------------------------- ----- I hereby certify that I have re r -------= ------------------ ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------.- y y p pared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. _ (Signed) -------,- --r ------------- By: ----------- (Der Contractor) B ---------------- ' Title ----------------- --------------------------------- (Plot plan, showing size of lot, location of system in relat' to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...... ----- -- --------- -- �� _ --- DATE---------�� -/` - REVIEWEDBY----------------------------- ---- ----------------- -- _ ------------•--------------------------------------- DATE------•---•--------•---------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------- ------ DATES----------------------------- ; t Alterations and/Pr recommendations:-=------- -_r"'_ - ,------ - ---------`----c'[�"--- -----,c�----------.---------A-----=----- ----------------------------------------------------------------------- ------------------------ }I , ^ . /.. FINAL INSPECTION- _ --- BY:.. �-- - �� ... ---��-�--�--�== Date--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-1S3 F.P.CD. r /'