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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, ... --------- - -------------- ------ ---------------- ------- --------- (Comple+e•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 Ordinance No. 5 9. JOB ADDRESS LOCATkON_____ - �2,—, -------- -------------------------- ----------------------------------------------------- ----- --- Phone Owner's Name --•----- -----•-------- --------- ---------------------------------------- Address---------- Q ---------------------------------------------------------------------------•-----------------------------------. ------------------------------------------- Contractor's Name..... G - ---- ------------- Phone.._.. . .�7��-------- Installation will serve: Residence {Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _./-_. Number of bedrooms —?---- 1 ___ Number of baths_/_._ Lot size __,.. -s_ - - ----------=---------- Water Supply: Public system 951Community system ❑ Private ❑ Depth to Water Table 0 r- ft 4` Character of soil to a depth of 3 feet• Sand ❑ Gravel❑ Sandy Loam ❑ Clay Loam ❑ Clay 2, Adobe Hardpan ❑ Previous Application Made: (If yes,date............. 1 No 9New 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 Tank: Distance from nearest well-________________Distance from foundation--------------------Material------------.----------------__._..___...______: i ❑ No. of compartments--------- ------------- --Size---------- --------- ----------Liquid depth------- Capacity Dispos I Field: Distance from nearest wO._�/_-e-.._Distance from foundation..../-0 ......Distance to nearest lot line-/a.-__-_-- ( Number of lines ar Iines.._._______lLength of each line-------1��__. . ......Width of french--------2-_� _� � - _.__._.Type,of filter material---- Y __,.__Depth of filter material Total length , Seepage Pit: Distance to nearest well- .-------------------Disfance from foundation------------------- to nearest lot line----------------- Nu m- ber _________._.--.- 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_._.__..________--------_.______..._____ ', ❑ Distance to nearest lot line-------- ---------------------------------------- -----------�----------------- -------------------------------------------------------------- 1 r- r -------- r - •------ 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)____ " "v _._.(Owner and/or Contractor) cit/ =tet tai --------- --------- By: - (Title} (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- y—--------------------------- - -- DATE 5� ------ - -- - -- -- ------------------------- - _._ DATE-----------.------------------- REVIEWEDBY--------- -------- - ------- - -------------------- ------------ ----- --- - - ---------------------------- BUILDING PERMIT ISSUED---------- - ---------------------------- --------------------------- ------ ---------- ---L----------- - ---------- DATE---------------------------------------------------------- Alterations and/or recommendations:------------ ----------------- ---- ------ { -------------------------------•--------- -----------•-------- - ._...---------------- - - -------------------------------- -------------------------------------- ------------------------------------------------ FINAL INSPECTION BY:---------- Date.... --•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. �y 300 West Oak Street 124 Sycamore Street 205 West 9th Sheet Stockton,California Lodi, California Manteca, California Tracy,California E.H.9 2M 1-67 Vanguard Press