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FOR OFFICE USE: - -- _ ....... APPLICATION FOR SANITATION PERMIT Permit No. .—................... 4? 1 (Complete in Duplicate) a, --------- This Permit Expires 1 Year From Date Issued Date Issued .....--._'-, "-L--.: Application is hereby made to the San Joaquin Local Health District for a permit to construct and�stall the v oA here-ifr described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION,--- ------------- -----------------------•--- Owner s Name-..-- 1¢ ' _ -•--- j --------- Phone - Address - --------------------------•---------------------------------- ---------------------------------------------------•--------- Contractor's Name---------fy-- .. - .. `' r ! ---------------------------------- - ---- ----------------------------------------------- Phone----------------------------------- Installation will serve: Residence Z?""Apartmenf House ❑ Commercial [ITrailer Court E] Motel ❑ E]Other Number of living units: -,/--- Number of bedrooms 2_ Number of baths /,y. Lot size '1¢ ------------------------------- Water Supply: Public system ❑ Community system ❑ Private RT-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 PErrNew Construction: Yes ❑ No R9--'FHA/VA: Yes @��No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tib, Tank: Distance from nearest welt.................Distance from foundation-------------------Material--------------- XLjj�l/A/C No. of compartments------------- ------------Size--------------------------------Liquid depth--------- --- - ----------Capacity----------------------- Z Disposal Field: Distance from nearest well-_. _---_Distance from foundation--------------------Distance to nearest lot ------ line.---------------_ Number of lines-------P) Length of each line-------/ �-.--------Width of trench-- -�--- --------------------- Type of filter material f � Q �Depth of filter material .11----.-----Total length...f�h�e-.�-------------------------- Seepage Pit: Distance to nearesf,well----------------------Distance from foundation-------------------.Distance to nearest lot line---------------.. ❑ Number of pits---------------------Lining material-------.---------------Size: Diameter.---------.------------Dept h---------------------.----------- Cesspool: Distance from nearest well-----------------Distance from foundation---_---------------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):.--------- ------ ------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- -------------------- ------------------------------ .X- -------il --- ------- - ------ -------------- - ------------- 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. J (Signed)--. -----------------------------------------(Ownervuoor Contractor] 1 By: --------------L 6th -- / . (Plot plan, showing size of lot, location of system in relafi to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_ - ------------------- DATE------ = Y - REVIEWED BY -- - - ---------------------------------------------- DATE-------- ----- BUILDING PERMIT ISSUED------------------ ---------------------- DATE --------------------------------------- - ---------------------------------- Alterations and/or recommendations-------------------------.............. - --------------------------------------------------------------•------------------- ---------------•--------•---------- -------- ---- ------- --- ---------- ----- - . 1. ' -,_ ------------------------------------------------ --------------------- - FINAL INSPECTION BY: i - �--- -------��-- - �---- Date----- _::------ -�-�- ..� if-..- �------ ------- - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 324 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVISED 8-59 r.P=.ZM 6-60