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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.--------------------------------------------------------- _._ �. ... ------------------------------------------------------- - (Complete in Duplicate) Date Issued --- ------------------------------------ -------------------- This Permit Expires I 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 compliant with County Ordinance No. 549. JOB ADDRESSAN LOCAL+ION_.S Lt1 - 4 --- - - - D5, y --Z Owner's Name =- ---- --- --- ----- -------- ---------------------------------------- Phone-------------------------------- Address........ ll•. /_..../ll -------- ) .%------------------------•---••-------_ - -- - Contractor's Name-------------- "S. S Phone - ---------- ----------••----------- ------ Installation will serve: Residence DI/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-_-_ Number of;,,bedrooms ., ; Number o baths __ Lot size __-_-_ .-__ .- ____________________ Water Supply: Public system El Community system E] Private 7 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E].-Gravel ❑ _Sandy Loam Z"-IZlay Loam ❑ Clay ❑ Adobe ❑ 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 ank: Distance from nearest well-____✓-----__----_Distance from foundation------6�.......Material------ - ---___. ___________________________ p y h �' -•Liquid depth------.�------------Capacity---- No. of compartments ___ __ _____________Size_ _. :-- Dispos Field: Distance from nearest well 40../___Distance from foundation_____��__�_.__.Distance to nearest lot line__-r Number of lines----------olf ------- ._-------------Length of each line �______-_-__._.Width of trench �_�_______________-________ Type of filter material__ t--_-__Depth of filter material-------1?-----_-_--Total length-------- d-_-------------------- Seepage `_________________Seepage Pit: Distance to nearest well------ ---------------Distance from foundation-------------------Distance to nearest lot line----------------- 11 Number of pits---------------------Lining material-----------------------Size: Diameter----------------------Depth-.------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_---.-._.______.________________.____. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ti Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-________.____________________________._. ❑ Distance to nearest lot line------------ ------------------------------------------------------------------------------------------------------------------------------- Remodeling 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 regulations of the San Joaquin Local Health District. (Signed)--------------------- - _ }1@4wit a and/or Contractor] --------------------- ----- : ./.------ ----------- ` Title Bye -v, r --- - ----- - { }(Plot plan, showing size of lot, location of system in reon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - ------------------------------------------------------------------ DATE-// ------ --------------------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE-------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-.------- ----------------------------------- --•--- Alterations and/or recommendations:---------- -- -- - - ------------------------------------------------------------------------------------------------------------------- ------------------ ------------- ---------------------------------------------------------------- --------------------------------------------------------------------•-----------•-------------------------------------------•----------- ------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------•---------------------------••------------------- -----------------------------------------------------------•--------------------------------------------------------------------------------------•------------------- -----••----------------------------------------------- FINAL INSPECTION BY/., Date----/---I----r--a------D-- --------------------------------------------------------- SAN --- ---------------------------------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 ES 9 REVISED 9-59 3M 3•'63 F.P.CD.