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FOR OFFICE USE: -- Permit______-__.. APPLICATION FOR SANITATION PERMIT Permit No. ... .f _. ....... --------------- -- ----------------------------- --- -- Date Issued ------ (Complete in Duplicate) � 4 --------------------------- -------. ------ This Permit Expires 1 Year From Date Issued ..............�63 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. JOBADDRESS AND CATION...--ZS-- --l----------- ------- ------ -----------------------------------------------------------------------------•-------------------------------- Owner's Name---/--- ---_------- ... ----------------------- -- Phone.................................... Address !- { ---- - -----(- Contractor's Name-------------------------------------•------------------------- -- ........... .....-- Phone-------•-------------------------- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/----. Number of bedrooms .a- Number of baths __`.. Lot size lee 11X`S-Q-�..................... Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table l ft. Character of soil to a depth of 3 feet: Sand [n 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.) r r Septic Tank: Distance from nearest well-S--Q--------Distance from foundation....ID?--------.Material-----p4e ... No. of compartments_.__a---------------Size3y__3'X_47..........Liquid depth-----',��--�';Z-----.-.-Capacity...Z_ Disposal Field: Distance from nearests well._5�....._Distance from foundation.. _ :-.--...Distance to nearest lot lin% AQ Number of lines---..---s�4---------- ---------Length of each line---Eo__. - --------Width of trench.....- - .....---------�.... Type of filter material...- 1__ Q '_Depth of filter material------ length------------------- A6.1r)...--.. � Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 17 Number of pits----------------------Lining material..._--__---.--------.-.Size: Diameter----------------------Depth--------------------------------- Oa Cesspool: Distance from nearest well.................Distance from foundation.-_-----........__..Lining material-----------------------------------I_ ElSize: Diameter-------------------------------------Depth------------------------------ -----------------Liquid Capacity--------------------•-------gas. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------_---------__-..--..._. ❑ Distance to nearest lot line----------------- ------------ -------------------------------------------------------------------------------------. -------------------- Remodeling and/or repairing (describe):------------------------------ -------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby ce if that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e ws, and r !es anI tigu ns of the San Joaquin Local Health District. 6 (Signed) ---- -- ------------------------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). n FODEPARTMENT USE ONLY APPLICATION ACCEPTED BY. ------------ ------------------------------------------- DATE.. .. .----�3--_------------------------ REVIEWEDBY------------------------------ ----------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED....................... -=------------------------------------------ - DATE-----.. Alterations and/or recommendation •..- -.._. ---- ------------------------------------- ---------- •---------- 1.. --------------------------------- ------------------------------------------------------•------------- ....------------------------ ---- .. --------------------------- ---------------------------------------------- ------ �. r FINAL INSPECTION BY:--------_:='" '"-` ------------------------------ 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 ES 9.REVISED 5-59 3M 3-'63 F.P.CC.