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r FOR OFFICE USE: 4 - -------------------------------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------- ----------- a ---------- - -------- ----------- -------------- pp / - (Comlete 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 describe : This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC Owner's Name---- ,»s.G ........... -- ----------------------------- Phone---------- hne ---- ---- --- -- -..---- ---------- ----Address-------------_----- - ..--V-.7------ ------ �--- -- Contractor's Name-- : -----•--------------•----•------------------------------------•------------------••-----------•--------------- Phone-------- ----------.--.------------ Installation will serve: Residence q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---r-.-. Number of bedrooms _�3--- Number of baths ?- Lot size r-------------------_---------.- Water Supply: Public system ❑ Community system ❑ Private p� Depth to Water Table4_O ft. 4 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes N3 No ❑ FNA/VA: Yes 11? No ❑ 3 TYPE OF INSTALLATION'AND SPECIFICATIONS: a/O� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well. -------- -----Distanc�fro foundation___.D .Material_. f - ------------------ PO No. of compartments.._..__--_-- .__5ize. '+ . --:--.Liquid depth_-_._'G1�______________Capacity �_� --___� Disposal Field: Distance from nearest well-_j6---------Distance from foundati 16______________Distance to nearest lot line.__-_--_---._ Ki Number of lines____ ____'`_.r, `._.___ __-__ ength of each line__.._ -------=-----Width of trencll_. - ------ -. Type of,filter materia _- -Depth.of filter material______ -_.-----_--Total length---r _-�0---------------__.-_.---. Seepage Pit: Distance fo nearest we I----------------------D--sstance from foundation--------------------Distance to nearest lot line------..-.._.--._ ❑ Number of pits----------------------Lining material---------- ----- -----Size: Diameter-----------------------Dept h-----------------_--------------- Cesspool: ------ ----.-Cesspool: Distance from nearest well__,y=------------Di'tanceffrom foundation------------------- Lining material_.----_'..._.-..-.------_---------.-.- k ❑ Size: Diameter--------------------------------------Depth.-----. ------------------------------------------Liquid Capacity--------------- -------------gals. ¢� Privy: Distance from nearest well----------------- -----__.-------_,-_---:_------Distance .from nearest building---_,-----------------------------------_ 1b ❑ 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 ordi es, State laws, and r s an egulations of the San Joaquin Local Health District. i I (Signe -------- ----------- ----- --- --�-------- - -------------- -------- - - ------------------------------------------------------------------ -----------(Owner and/or Contractor) (Plot plan, showing size of lot, location of system in relation to --------------------------------------wells, buildings, etc., can be placed on reverse side). b FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ----------------------- ------- DATE----' .------------- 1 REVIEWEDBY---------------------------------------------------- ------------- ---------------------------------------------------------- DATE---------------------------------------------------------- BUILDING ----- ---------------------------- BUILDINGPERMIT ISSUED----------------------- --°'------------------------------------------------------ -- ---------------- DATE------------------------------------- -----------=------ -- Alterationsand/or recommendations---------------------- - --------- ---------------------------------- ------------------------------------------------------------------------------ ----------------• ------------------------------------------ -------------------------------------- -----------------------•--------------------------------------------------------------------------- I - i -------------------------------------------------------------------- ------------ - - ---- -------------------- -------------------- ----- -------------•-•-----------------_----------�- ------------- ------- --------- ----------------------------- --- -• ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ------------------------ --------------------------------------------•----------- -------------------------------------------------- --------------------------------------------- --- ------------------------------ Date ----------------------------- v 9-14r 4r FINAL INSPECTION BY./ _i�..rp-!' 4 A Date. l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street `t 124 Sycamore Street 205 West 9th Street Stockton,California M Ledi,California Manteca,California Tracy,California � CS 9 REVISED 8-59 3M 3-'63 F.P.CD. A