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FOR OFFICE USE: --------------------------------------------------------- r a APPLICATION FOR SANITATION PERMIT Permit No. ----------------------- -------------------------------- \ (Complete in Duplicate) 8` .......................................................... This Permit Expires 1 Year From Date Issued Date Issued .._... 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 com fiance ith County Ord' %e blq. 549. GGA'- JOB AA� AT � � /_- y 1 7- --- ------------------ ------- Owner's Name...... -------•--------------------------------------- ------------•--- ---------------------- Phone.................................... Address ,r '?' �^;,' 1 7 �- ----------------------------------------------------------•---•-------------•-----------.----------•- Contractor's Name-----A �--------------------------------••------------------------ ------------------------------------------------- Phone................................... Installation will serve: Residence q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1------ Number of bedrooms ----- Number of baths 1----- Lot size ---- ....................................... Water Supply: Public system ❑ Community system ❑ Private g] Depth to Water Table .-'f.-Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 21 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No W 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---••- ................ Disposal Field: Distance from nearest well--ryo......Distance from foundation.... ' ..._...Distance to nearest Iodine.-1.......... Number of lines--_,�............ ... Length of each line..../, trench. .�{. ._..__....._...Width of ., .�._"_...._......._.._..._. Type of filter materia __ Depth of filter material_.±��''.-..-----.Total length-1-J/Q'........................... 111,." 00 Seepage Pit: Distance to nearest well...:..................Distance from foundation--------------------Distance to nearest lot line----------------- 0 ❑ Number of pits......................Lining material--------.--------------Size: Diameter-----------------------Depth---------..---------------------- 0 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well.......:......................... ----.-__Distance from nearest building------------------------------------------ 171 Distance to nearest lot line---------------------------------------------------------------------------------- ---- S► Remodeling and/or repairing (describe):----------------------------------..---------------------------------------------------------------------------------------------------------------------- 00 --------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------•-----__._-..-••----------------- 0 ---------•---•-------•-------------------••------------------•-------------------------------------_----------------------------•---•----------••-------------------------•-•-------------------•------------------r VIP ------------------------------•--------•------•------•---------------------------------------------------------------- ----------------------------------------------------------------------------------------------- I hereby/ceify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Slaws, and rules and regulations �f the`San Joaquin Local Health District. (Signed)__.__._.- ---A.-.- -----------------------(Owner and/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--- ------------------------------------- REVIEWEDBY---------------------------------------------------------- ------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- --------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------------------------------ ---------------------------------------------------- --------•------------------------------------------------ --------------------------------------------------- -------------------------------------- -------------------------------------------.....-------------------------------------------------....................... ---------------------------------------------------------------------•---- ------------------•------------------------------•------•--------------------------------------------------------------------------------------- -------------------------------------------------•------------------------------------------------------ --------------------------..........------------------------------------------------------------------------ ------------------------------ - ---------------------------------------------- --------------------------------------------•------------------------ ------------- ---------- --------------------------... FINAL INSPECTION BY:.- ?��. ` 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 8-59 3M 3-'63 F.P.CO.