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FOR OFFICE USE: -------------------------------------------------- -------------------- - APPLICATION FOR SANITATION PERMIT Permit No. ---------- ------------------------- . .. - D � (Complete in Duplicate) �r Z 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 hereinscribed. This application is made in compliance, with County Ordinance No. 49. 0(p•3 JOB ADDRESS LOCATION-� � ft--------- Owners Name .(-s ��a------- - ---------- Pho e Address- `. -- - -------- -- ---- -----------------•- •------------------- ------------------ Installation G` -- Phone Name -- --- --- - --- - ---- - -- ---- ---- ------- ------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms __�_4 Number f baths/-__ Lot size ______________ Water Supply: Public system El Community system E3 Private 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-----------.........I 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 Tank: Distance from nearest well-----------------Distance from foundation--------------------Material------.________.__._______.__-_-.__.___...______- 171 No. of compartments-- --- -------------------Size---------------•---------------Liquid depth----------------___---Capacity...-------------- Disposa field: Distance from nearest well__/,�c0_/---Distance from foundation--- _._.------Distance to nearest lot line_ _________- Number of lines--------1 Length of each line------1_L5_Q___-.___.Width of trench...__ .-_--------------- ___ 0 Type of filter material. Depth of filter material----,-:./Z._____Total length------1e.6------------------------ Seepa Pit: Distance to nearest well_.__ _Q _---___Distance fr undation-__-_1 Q_____.Distance to nearest lot line__.>�... Number of pits_______/...______Lining material_r ------Size: Diameter______ _----______________ ` 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-- --- -------------------------------------- - -----------------------------------------------------•----------------•--•-------------------- 0'0 Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------•----------- -------------------------------------.------------------00 ---------------••---•--------------------------------------------------------•--------------------------------------------------------------------------------- -------- -------------------------------------------------- - t� --------------------------------------------------------------------------------•----------------------------------------------------------------� CI I hereby cer ' y at I have prepared this application and that the work will be done in accordance with San Joaquin County 'h ordinances, Sta la and rules and regulat' s of the San Joaquin Local Health District. (Signed)------ - ------ ------- --- - - -- - ---------------------------------- - ----------------- - nd/or Contractor) �Y� ----------•---------------------(Title)---------------------- ----------- ---------..---------------- (Plot plan, ing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------------------------------------- DATE--- a-=` --------------------_--.- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------•---------------------------------------------- BUILDINGPERMIT ISSUED-----...-•.... •-------------------------------------------------------------------------------------- DATE--------------------------------------- --------------------- Alterations ----------------- -Alterations and/or recommendations-------------------.------ ------------------------------------------••-----------------------•-•----------....---------------•------------------------------- ------------------------- ----- -------------------------------------------------------- ------- --------------------------------------------------------------- ------------------------------------------------------ FINAL INSPECTION B ---•---------------- Date.-- ��--- -Y-------------- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California G.9 9 REVISED B-59 3M 3-•63 F.P.CD.