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FOR OFFICE USE: ------------ h A��.� 1 c/ ------------------------- ------------------- V /► , APPLICATION FOR SANITATION PERMIT Permit No. ../. ....... ------------------------------ ------- --------- -------- (Complete in Duplicate) -_ ................. This Permit Expires 1 Year From Date Issued 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 compliancq y✓ith County Ordinance No. 549. JOB ADDRESS AND L CATIO _ '" -- �---- - Are_(E)ti__ Owner's Nam -- - - - -- ----------- ------------------------------------------------------------ Phone.................................... Address--_V-` .'----- . ....-------cAA .......... ---��•----- Contractor's Name............. �`......-- v1_� .-- . ................................................ Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._r.... Number of bedrooms _,3-. Number baths ___/__ Lot size __''tomst - —+ �-___________________ Water Supply: Public system ❑ Community system ❑ Private Number Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ r 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 T k: Distance from nearest well______--_--Distant t from foundation-----/0___-___--.Material...4 _ ------_.__.-_-.-____-._;__--__.- - No. of compartments_---_-.?-------._.__--_Size... __fit_. ._X__ ..Liquid depth------- _.'.........----Capacity....84J. Je Disposa field: Distance from nearest well---SiP_/----Distance from foundation....L_l?_..........Distance to nearest lot lines.......... Number of lines.......... ________________Length of each line-------- --------width of trench-_-,;X............._____,__...... Type of filter material__--C_--_Depth of filter material-----LIZ`.......Total length--------ZJPJP_..................... Seepage Pit: Distance to nearest well______________________Distance from foundation---:_._............Distance to nearest lot line----------------- V ❑ Number of pits--_-----------------Lining material-----------------------Size: Diameter-_--------.__::......-.Depth .......................... Cesspool: Distance from nearest well-----------------Distance from foundb Ion___-._._.......,,,_.Lining material_:.--__----__.______.........._._._._ ❑ 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):_(9_ __________________..___._____._ ------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. _-n (Signed) -------- - ------------------------- --- a d/or Contractor) f� BY: -- -------- ----------- - Y -(Title) (Plot plan, showing size of lot, location of sys+em in relation +o wells, bu dings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - ---- - - - ------------------------------------------------------•. DATE-----. ----------------.--._ REVIEWEDBY----------_-----------------------------------------------------------------------------.................................. DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------•--•- Alterationsand/or recommendations--------------------------------------------------------_--------------------------------------------------•---------------•----------......__.......-------- --------------------------------------------------------------------- •------------------ -----------------------------•-----------------------------------------------------------------------------•--•------------------- -----•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- -------------------------•----•------------------------- --------------------------------- --------------------------------------------••---•------------.,......- ................. ---------------------------------- ---------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------= FINAL INSPECTION BY:...44 =� L Date_ -----------b 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 5-59 3M 3-'63 F.P.CD.