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FOR OFFICE USE: _ 75 --------------------------------------------------------- _---.- - APPLICATION FOR SANITATION PERMIT Permit No. .. .................... 4-7( ( - ----------------------- ---------------- (Complete in Duplicate) / T-V--------------------- - Date Issued .-----!_-�.��. _-_.._..........________________________ This Permit Expires 1 Year From Date Issued A Application is hereby made to the San Joaquin Local Health District for a permit to constructall the work herein described. This application is made in complianctt��e with County Ordinance No. 549.�j JOB ADDRESS AND L CATION, ! ---- ---- ----=- '__---- ----------------.------- Owner's Name--------j s._-ll1-./ 4't.-------- ----- Phone......__.---•--•--------------- Address --•--•----------------------•------ --- Contractor's Nam -- ,._� ,�? �� . � Installation will serve: Residence .V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1----- Number of bedrooms __ _ Number of baths ___/___ Lot size __ " . __ _ ----------------_______________ } Water Supply: Public system ❑ Community system ❑ Private.W Depth to Water Table'. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 2 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: ..F (No septic tank or cesspool permitted if public sewer is available within 200 feet_.) Septic Tank: Distance from nearest well--- Q_.-_Distance from foundation___)_ ________. Material____________________________ ra ----------------------- 4 No. of compartments-___2 --- ----- -----Size---'�7•Y_---=r-------Liquid depth------�.......----- --Capacity?--- -------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-_____-_.__..._.. ❑ Number of lines-----------------------------------Length of each line---------_------------------.Width of trench--------------.--------------------- ' Type of filter material-------------------------Depth of filter rmaterial-----------------------Total length__--_-_-_-_-_____.-____-_-__---_______ Seepage Pit: Distance to nearest 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-----------------.-.------_-_________- Ac ❑ Size: Diameter---------- ------- -------- ----------Depth•---------------------------------------------------Liquid Capacity_--------------------._--gals. Privy: Distance from nearest well----------------_------------_____.------.......Distance from nearest building----------------------------------------- F1Distance to nearest lot line----------------- ----------------------------------------------------- ---------------------- ----------r---------------------------------- Remodeling and/or repairing (describe): ,. s -.._--------••---••--•--••---•-•-------•-----------•--------------•-- z1v----------------------- -------------•--------•---------------•------------------------------ - ---------------------------------------------------------------------------•---------------.•---------------------•--------------------------•---....-.-------------------------------•-------------------.--------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ill ordinances, Si ate laws, and rules and regulations of the San Joaquin Local Health District. w (Signed) -- - -------------------- 5 (Owner and/or Contractor) BY -------------------------------------------------------------------------------(Title)------------------- -------------------- --------- �` (Plot plan, showing size of Iot; location of sys+em in relation to wells, buildings, etc., can be placed orrreverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ---------------------------------------------- DATE--- -5 ---------- REVIEWEDBY--------------------------------------------- -----------------------------------------------------------------------------. DATE--------------------------------- BUILDING PERMIT ISSUED-------------------------------- ------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------------------------------------------------------- ------•- ----••-----.._.--------------------------------------- ----------I-------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- -----•--------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------- ----------------------------------------- ----------------------------------------- -------------------------------------------•------------------------------------------------------------------------------------- FINAL INSPECTION BY:- ? t1.r ----------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 Weal Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 5-59 3M 3-'S3 F.P.CO.