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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.- ............. ... -------------------------- -- -------------------------- (Complete in Duplicate) Date Issued ________________________-_-_--__._-_ This Permit Expires 1 Year From Date Issued a 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. JOS ADDRESS AND LOCAT N ✓- (! , ??. Owner's Name__` y�jC� ------------------------------------------------=--------------------------------•--•--------•-- Phone Address-------- ............................----•-....................----•-------------------------------------------------------------------.--------------------------------------------------- .. Contractor's Name--• •-- _. _---••------- -------------------------------------------- -------------------------------------- Phone-------------_---------.......- . Installation will serve: Residence !0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ._. Number of bedrooms .tY_ Number of baths _/--- Lot size 4---- ----------------------------- , Water Supply: Public system ❑ Community system ❑ Private 2--'Depth to Water Table 70- ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,dates___________________) No [! New Construction: Yes ❑ No ® "'_FHA/VA: Yes ❑ No R�' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:/ Distance from'enearest well-----------------Distance from foundation--------------------Material------------------------------------------------ . (�7/�� No. of compartments--------------------------Size---------------- ------ ---------Liquid depth-------------------=-----Capacity----------------------- D;sposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line______________--- i Number of lines-----------------------------------Length of each line-------_----------------------Width of trench...........................•------•- !�/`� Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ 471 Seepage Pit: Distance to nearest well---1.19415___----Distance fjJ�m fo ndation__,/�---.-__-.Distance to nearest lot Number of pits------/--_------.---Lining material- 1i✓��rX- Size: Diameter___-�j-`'____Depth---Z4-- - �l]} ------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------- E] Size: Diameter---------------- - -------------.__.Depth------------------------------------------- --------Liquid Capacity_--------------------------gals. _n Privy: Distance from nearest well--------------------------------------------- ---Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line-------------- -- ---------------------------------------------------------------_--------------------- ----- ------------------ i Remodeling and/or repairing (describe):-------_ -- ------------------------------ -----------------------------•--------------- -- - --------- ----- ---- -- - --------------------- -----------------------•---------•--- ----------- ------ ---------- ----------- --------- ----------- ____ -______--- _ _ ________ -------------------------------------------------------------_-_ J I hereby certify ta I have prepared this pplication and at the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and egulations of the San Joaquin Local Health District. i . (Signed) -----------` -- ---- --- :------=---------- -( /or Contractor) By:----------------•--.....---__-------------------------- ---- =----- {Title) d��' (Plot plan, showing size of lot, location o s em in relation to wells,"buildings, etc., can be placed on reverse side). k 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- -------- ---- ---- -------------------------------------- DATE------ �� ' REVIEWEDBY-------------------------------------------- ------------------------------------- DATE------------------_----- - ....... BUILDING PERMIT ISSUED---------------------------------- ------- ------------------------------------------._ DATE--------------------------------- -------------------------- jAltera#ions and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------ --------------------------------- ! A / _-_-______________________/' �..__________________ ________`�_______ _______- ..______.__ _._-.-.-____--__-__._____._____________.-_____--._--.--...---_-..---•..__________-_--__-_____________.______._____---.._.... __________________________ ___ ---------- _..._______._. `�� FINAL INSPECTION BY:- 1 Date. t � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 1 ES-9 AEVIOEo 0.59 F.P.rc.2M 5-60 4