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Permit No. _ _ ? APPLICATION FOR SANITATION PERMIT -•----•- (Complete in Duplicate) Date Issued This Permit Expires 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 Ordina ce No 9. Af JOB ADDRESS AND L CATI - ----- ------- -----------------------------------------------=--------------------•------------ i Owner's Name-- -- --'--•- -- - - - ------------• -------------•- ----------------------------------------------------------------- Phone----------------------------------- Address----------- - ! ---- -- ------------------------------------------------------------------------------------I------------------------------------- Contractor's Name----------- ----------- ------- -----•---------• -------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Z] Apartment Hous Commercial PRO'Trailer Court [] Motel ❑ Other ❑ Number of living units: -------- Nu`m�5ei off`bedrooms __''Number of baths _-f_. Lot size ----------------------------- Water Supply: Public system [Community system ElPrivate E] Depth to Water Table -Y-A'ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2"Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes R!r�No ❑ FHA/VA: Yes ❑ No P-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) r Septic Tan '• Distance from nearest well____-�""--___Distance from foundation_______��-.Material------ �----- -_ __!__ ..___-_____- L9 No. of compartments-----x _ Size_. -��-�-��-°'.Liquid depth______ __- � ---Capacity � Disposal Field: Distance from nearest well----------Distance from foundation--_ _-0----___Distance to nearest lot line___ .' ' W-000 Number of lines---------/-_______ ___________length of each line---------&0--�----------Width of french-�.__.q ,"----_--__--_______ Type of filter material---/-j epth of filter material____ ------Total length______/ "- fr?_________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-__----___-_____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------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_____._____________________-------__---_. i ❑ Distance to nearest lot line----------------- ---------- -----------------f------------------------------------ ----------- �-- "Remodelin9 and/or repairing (describe):-------------- - -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------•--------------------------------•-•----------------------------------------------------------------------------------:---------------------------------------------------- -. - ----- ------------------------------------ -- -----------------------------------------------------------------------------•----------------------------------•---------------------------------------------------- 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 reg lations of the San Joaquin Local Health District. (Signed) 'e ----------------------- - ( *r Contractor) � - ------Title--- - - - ---�'p`-- - . rw (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ------------------------- ------------------------------•------------------------•- DATE-------------------------- --------------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE-------------------•----------------------•--•------------ BUILDINGPERMIT ISSUED------------------------ ---------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations-------------------------------------------------------- ----------------------------------------------•-------------------------------------------------------- - ---------------------------------------------------•--------•-----------------------------------------------------------------------------------------------..---------------------------------------------------•----------- FINAL INSPECTI6tdDate------ / /— 5 -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street .300 West Oak Street 132 Sycamore Street 814 North "C" Streetf' Stockton, California Lodi, California Manteca, California Tracy, California ; ES-4-2M Revised 8-'59 F.P.CO. � 5