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FOR OFFICE USE: -------- --- --------- -- ------------- --- APPLICATION FOR SANITATION PERMIT Permit No. .. .., :?...... --------------------------------------------------------- (Complete in Duplicate) --- _________________________________________________________ This Permit Expires 1 Year From Date Issued G��" / Date Issued lx_ 161�1 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. 549. JOB ADDRESS rANDCATION�o2.?tW Owner's Name �------'��`-Z �[ ----�-.--.--.-.a-,•_P_.h�one�--.-.-_-�------"-�--------?-.-.- ------------- Do.; Contractor's Name------ -- - ` =',` u`" = �= Phone ------------------------- Installation will serve: Residence Qj Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:=__�___ Number of bedrooms _�___ Number f baths .__ .. Lot size _________________ _________ 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 ❑ Previous Application Made: (If yes,date--------------------) 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__________-_____-_-_.-__:_--_---_--_._______--•-. ❑ No. of compartments-------------------------Size----------------------------_---Liquid depth--------------------------Capacity---------------------- Dispos 'Field: Distance from nearest well... `_-__---Distance from foundation....«LQ.........Distance to nearest lotline.....s._...... Number of lines..___._.�...___.. _______________Length of each line______�'P..._-__......_...Width of trench-__�---------------------------- -------------- - .. Type of filter material - ----Q_�____..__Depth of filter material_______1.?".._.._Total length........4.0___________________________ �1 Seepage Pit: Distance to nearest well____________________._Distance from foundation....................Distance to nearest lot line................. A ❑ Number of pits______________________Lining material-.._-_-_-_-.-._-_-_-.-.Size: Diameter-----------------------Depth..------------------------------- Cesspool: Distance from nearest well--------------___Distance from foundation---.----------------Lining material------------------------------------fid ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------------ gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building_-______.______------ _-•-_..._-__--.-- ❑ Distance to nearest lot line--------------------------------------------- --------•-•-----------•------------------------------•-----•----------------------------------- Remodeling and/or repairing (describe):--,/-;::) -------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)----------�------------------_ - ------- n ---------------------------------------------�-- or Contractor) By:---- ----,- '` `----- - ---------------------------------------(Title)----------------------------------------------- --- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-__-__ DATE ° r ---------------------------- --------------------------------------------------------- .----------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- ------ DATE------------------------------------------------------------ Alterations and/or recommendations-------------------------------------------------•--------------------•--------------------------------------•------------------------------------------------- -------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- ----------------------•-----------------•-----------•----------------------------- ----•---•--•--•-----------•--------•--•--- .................................................. -------------------- --------------- ---------------------------------------------•-------------------------------------- -----------------------------------------------------------------------•-•--------•--------------------------------------•---------- ------------------------------------------------------------------------------------------------------------------------------------- ---- ------ ----- FINAL INSPECTION BY------ -:A,1!4 ---------- Date---- -- '`y---- ------------------------------------------: SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-S9 3M 3*'63 F.P.CD.