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FOR OFFICE USE: _- APPLICATION FOR SANITATION PERMIT Permit No. - (Complete in Duplicate) 'S 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 Ordinance No. 549. JOB ADDRESS AND LOCATION11'u` j� �'a '--4�------•------------------------------------------ ° CSG----- --=------------------------- - ---- Phone----------•-•-----------•--•-------- Owner's Name-------------- ------------•• -•--•-------------------------- -------------- ------ --- - Address-------_------•----------r /__ Contractor's Name--•--s----- - - ----- •----------- - Phone Installation will serve: Residence ' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _!_____ Number of bedrooms _y__ Number of baths J____ Lot size ____________.__._ Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam, Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No)Rj New Construction: Yest No E] FHA/VA: Yes ❑ Nogy TYPE OF INSTALLATION AND SPECIFICATIONS: � (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic,Tank:i Distance from nearest well-----------------Distance from foundation--------------------Material ______.__________.._____..______- Noof compartments--------------------- ---Size--------------------------------Liquid depth--------------------------Capacity----------------------- i Disposal Fidl Distance from nearest well------_-------__Distance from foundation---------------------Distance to nearest lot line________-_____... 1 Number of lines-----------------------------------Length of each line---------------------------_Width of french--------------------------.___---_-- Type of filter material---------------------„__Depth of filter material------------------------Total length------------------..-----------'__________ Seepage Pit: Distance to nearest well_ ___________L_ ':stance f "oundafian } line �`�� .____d___.__. sta ce to nearest lot ___ Number of pits-----/--------------Lining material--- iameter_____.'-3-----------Depth----2-C ------.-------.. V1 Cesspool Distance from nearest well-----------------Distance fr _----_--_.__.-._.Lining material_------___.._--_______.______________ ❑ Size: Diameter---------------------------- ---.Depth------ ------- ------ ------------------Liuid Capacity------------------------ gals. Privy: Distance.from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F-1 Distance to nearest lot line---------------=--------- --- ------------------•-------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)=--------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------•-----------•-----------------------------------------------------••-------------------------------------------------- ------------------------------------- N. ------------------------------------ ---------------------------------------------------------------------------------------------- --------------------------------------------------------------------- ------------------------------- -----------------------------------------------------------------------------------------------------------------•- ----------------------•-------- "---------------- G I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate laws, and rules regulat' ns of the San Joaquin Local Health District. (Signed) --------- ---; . . ----------------------- (Owner and/or Contractor) `_ ---------------`------------------•---- = (Title) (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 l 1 v APPLICATION ACCEPTED BY-------------------------- --------------------- --- ----- --•- --------------------------- DATE--------------------.---------------------------------------- REVIEWEDBY------------- ------------------------------- --.--- -- ---- -- ----- --------- --------------------- DATE......j j-^=� ..��---------------- BUILDINGPERMIT ISSUED---------------------------------------------- ----------------------- DATE------------------------------------------------------------- -----------and/or recommendations:---------------- - -------- ------------------------- •-------------------•---•--------- --- ----- f ----------------- ------- --------- ------ ------- --- FINAL INSPECTION BY---------- ---`'=---- ---------------- ------------------- Date------ -- y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street *124 Sycamore Street 205 West 91h Street Slock�a,California Lodi,California Manteca,California Tracy,California FCS 9 REVISED 8-59 3M 3-'63 F.P.GO. 1