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FOR OFFICE USE: "I APPLICATION FOR SANITATION PERMIT Permit No. .. d.__., -------------------------------------------------------- j ------------- ----------------- --------------- (Complete in Duplicate) / y„ 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 cons ruct and install the work herein described. This application is made in compliance with County Ordinance No. 54g,�O� JOB ADDRESS tolQ LOCATION- Wt_v-_--- - Y -- c'f-�• -- `- ��Q�"" �' < a Owner's Name - --------------- •---•---•---- Phone----................................ Address----- --- L� - -- -- - - -------------------- -- - --- - ------------ - Contractor s Name F'� 7� P ------------------------------------ Phone..................•................ Installation will serve: Residence ff� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ `Other ❑ Number of living units: _1_._. Number of bedrooms I___ Number of baths __I_.. Lot size ------------------------------- Water Supply: Public system ❑ Community system ❑ Private e 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--------------------) 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__._'r0_-__---_Distance from foundation..! °_ __.____.Material___.44. ____Iff _.}__....__.. No. of compartments-------'�-._------ Liquid depth-------A/_-------------Capacity...f.2__� Dispos ield: Distance from nearest well___-XA_. _._Distance from foundation.1 f.............Distance to nearest lot line—X........... Number of lines_________ _______________________Length of each line---_._ " _____.__...Width of trench.__. .�_.,..___._.._._.____.__ Type of filter material....4, _t-------Depth of filter material__-----I__`!_ _..Total length----------, ..`................. 00Seepage Pit: Distance to nearest well---------_______......Distance from foundation__..................Distance to nearest lot line______..._..__... Q ❑ Number of,pits-----------------__-Lining material.----------------------Size: Diameter-------_...._.---__Depth---.---------_------------------- j Cesspool: Distance from nearest well-------____----__Distance from foundation------------_-------Lining material-------_www---------------_____-._.-. ❑ Size: Diameter--------------------------------------Depth---------------------------- ------------.-Liquid Capacity__---------m------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--_.---___-_----__-_____-_-.-.-.._._._-__. ❑ Distance to nearest lot line----------------------------------------------------------------------------•----------------------•----------------------------- Remodeling and/or repairing (describe) �-----------------A-----------------------------•----------•--------•------•---•------------------------------------ •---•----------------- �b ---------------------•--------•-------------------------------- ----------------------------..------------ ----------- -----------------•-------- ------------------ ---------------- -----•------------------------------------------------------- -----•-------------------------•------------------------------- 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)--------------- --- --------- ------ - --------------------------------- ------------ ----------- ('�'r and/or Contractor) ------------ By:-------- Title -------- - - (Plot plan, showing size of lot, location of system in rely n to wells, building's, etc., can be placed on reverse side). FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY--- _ " ______________----------- REVIEWEDBY--------------------------------------------------------------------------------------------------------------•---------_-- DATE..--------------------------------------------------------- BUILDINGPERMIT ISSUED_--.....----------- ---------------------------------------------....................-....... DATE------------------------------------------------------_---- Alterationsand/or recommendations:----- ------- ---+•--------------------------------------- ...................................------------------------------------------------ ------------------------ ------------------•---.........---------------- -------------------------------------------------------------------------------------------------------•••--•------------------------------------- ---------------------------------------- --------- -------- --- ---------------------- -----------------------------------------•- --------- --------------- -j FINALINSPECTION BY:.-- --- ---- - '- _r - ---------------- Date--------------- . ------------------------------------------- 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 E$ 9 REVISED 8-59 3M 3•'63 F.P.CD.