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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .__../. - ------------------------------------------------------ (Complete in Duplicate) �Sf Date Issued ------------------------------------------------ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit t c nstrucb 91 irYs� ll the rk herein described. This application is made in compliance with County Ordinance No. �� JOB ADDRESS AND L C T Owner's �; -- ` ---- v1� r ama-------- -v -a °vt_ .------'------ -- ---------e h�ne--------- Address.. - ---- ------- ------- 3 . .._. .. -----------•----- •---•---•------------ -A Contractor's Name__. -- Phone------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .____ Number of bedrooms 4--- Number 'baths ___,�!Lot size __ �______ ___________r'____._---_-__ Water Supply: Public system ❑ Community system ❑ Private Depth Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ i Previous Application Made: (If yes,date--------------------l No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ t 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--------------------------------------._________- ❑ 10 No. of compartments--------------------- ---Size:----------------------------=---Liquid depth--------------------------Capacity..------------------- Dispos Field: Distance from nearest well... JPO_...-Distance from foundation__1Q--- ____Distance to nearest lot line____---_____ Number of lines---------- Length of each line-----/-01TWidth of trench_._Z_�--------- ----------- T .- -a Q r Ty pe of filter material___ _.- _ __;_-.__Depth of filter material_______r_____________Total length-------1_&>/-&10------------------------ 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----------------- from foundation___----------------- Lining material.__---------------------..-_-_-_--.-- C ❑ Size: Diameter-_' ----------------- Depth -----------V - Liquid Capacity gals. Privy: Distance from nearest`well----------------------------; -_.` `___-`"Distance from nearest building______________________________-__--___--_. ❑ Distance to nearest lot line--------"----------------------1-----------------------------------------------=---------------------------------------- - 1A Remodeling and/or repairing (des ):_____ t ` a --•---•--------------------- ------ --------------------------------------------------------- ------ ------------•------•-•----------- ----------------------- --------#--------- -------------_------V------------------------------------ -------------------------------------------- `.�,.- I hereby eerfify that I have prepared this application and that the work will be done in accordance with San Joaquin Counfy ordinance$,-State I s, and rules and regulations ofAe San Joaquin Local Health District. (Signed)-------- - ----- and/or Contractor) ------- --------------------- -- ------- --------- BY= g._ 06-- ` (Title! -- --------------- (Plof plan, showing size of lot, location-of:system.in.relat n to wells, buildings, efc., can be placed on reverse side). I ` FOR DEPARTMENT,USE ONLY ' APPLICATION ACCEPTED BY___-____._ _10REVIEWED BY ----- ------=--------- DATE BUILDINGPERMIT ISSUED-------•--------•---------------------------------------------—-------------------------------------- DATE--------------------------------------------- Alterationsand/or recommendations:----------------------------------------I-----------------•----------------•--•----------------------------••--------•--------------------------------------- -----•--------------------------------------------------------------------------------------------------------------------------------- ------------------------------ ------------------------------------------------ --------------------------- -- ....... ------------------------•-----------------------------------------•--------------------------------•--------------------------------------------------------------- ------- r FINAL INSPECTION BY--------- - --------- ---------- Date---- ----` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoselton Ave. 340 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3••63 F.P.00.