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T. FO OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------------------------------------------- -- (Complete in Duplicate) Date Issued .--•.--1-� _--_-- I --------------------_-----_-------------_---------------- This Permit Expires l Year From Date Issued Application is hereby made to the San JoaquinLocal Health District for a permit to construct and install the work herein described. This application is made in compliance with County`Ordifi'6ce N v V JOS ADDRES A D LOCATION ' = b �` O._.- ---------------------------- --- ------------------------------- Owner's Nam _ ; --: --•- - Phone..--••--------- - - ---••--- --------------------•------•------ ---------------- -----------------•----------- --------- ---- --------------------- Address__---_______ ' -------------------------------- •-.----- --- Contractor's Name •-- ------------------------------------------------ Phone..._.... Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.--/-- Number of bedrooms a Number of baths _/___ Lot size 4?;__�� ----___________________________ Water Supply: Public system Me"Community system ❑ 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: {lf yes,date----- [:]i- ----1 No New Construction: Yes E] No ❑ FHA/VA; Yes [__1 No El x TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted..if public sewer is available within 200 feet.) - Y---- —�-�--- Sept Tank: Distance from nearest well-----------------Distance from foundation_____________3____Material__.------------.------.�---------- ----._-__.___. ` /� No. of compartments---- Size=�f•--------•----'------------Liquid depth Capacity Di poo Fieick Distance from nearest weli_________________DIsta Distance from foundation______._____ ___.Distance to nearest to line..__--_.._--_._.. ' d�r`/+� Number of lines-------•------------------------Length of each line------------------------f----.Width of french--------- ------------------------ Type of filter material-------------------------Depth of filter material-----------------1....Total length-----------.____4____________________.____ Seepage Pit: Distance to nearest/welL_____�^--_____Distance from fo clation______.� .:._ .Dist nce to nearest lot line_________ ®� Number of pits_____!______________Lining material--,"' _Size: Diametet-,"T/" Depth___ Cesspool: Distance ,from nearest well-----------------Distance from foundation--------------E-----Lining material_________-_.-____.______.________- Size: Diameter---------------- -- -.Depth-------------------- ------------------------------Li_ uid Ca aut 4 als. Privy: Distance from nearest well-------------------------------------------------I from nearest building________-___-___-________-__-__-___._._. 1 ❑ Distance to nearest lot line----------------------- •--------------------------------------------------------------------------------------------- Remodeling and/or repairing`! (describe):------------- l - ------------------------------------------------- --------------------------------•-------------- _ --------------------------------•-- --------•------------------ --- --------------•------ I 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, anj rules and regul tions of the San Joaquin Local Health District. i (Signed) _ Contractor -------- - - -- ------------------------ � 1 } By:--------------------------------------------------------------------- -- (rtle)__. � .. (Plot plan, showing size of lot, location of system in a Ian #o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-.--.---------------------------------- ---------------------------------------- DATE-------{ y----------------------- REVIEWEDBY--------------------------------------------- ---------------------- - ------------------------------------------------------ DATE------ --------- BUILDING PERMIT ISSUED---------------------------------- — --- DATE.--------------------- i ____----------------------------- ----- Alterationsand/or recommendations------------------------------------------------------------------------------------------------------------•---------•--------------------------------f----- •------- . -_ .:, ---------- --------- ----- --- ------- ---- -- i ------------------------------------- -° `? ----------------------------- -•� '-, e ----- --------- --------------- ----- --- -------------•--------------------------------------•--•- ---- __________________________________________-----------------------------�__.__ 5 ---------- FINAL INSPECTION BY-------------- -- ____-- =-- ------------- Date........... _ -- -- -- -- SAN JOAQUIN,LOCAL H_ EALTH DISTRICT, ' 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamr Street s 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.CD.