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FOR OFFICE USE: --------------------------------- � ---------------- ------------------------------------____--_-__-___-_._. APPLICATION FOR SANITATION PERMIT Permit No. .._..../..........;... --------------------------------------------------------- (Complete in Duplicate) -------------------------------------------------- I 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 compliance with County Ordinance No. 549.. . p JOB ADDRESS AND LOCATION______ __ _ _ -- -__.v- - f w►- .C.c--- , --•-__rZcla. . Owner's Name.--- ...-- - .� .� -------- ----- Phone__?`-- AS'---- Address -=---..... .......•. ---- -- - --•- --•----------' n . ---- Contractor's Name-------- 0'.... ........-----------:-=----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �) Number of Living units: ---j---- Number of bedrooms __3__ Number of baths ___ "'Lot size ...__/_. - ----------------------------------------- Water •g---_____________________________Water Supply: Public system ❑ Community system ❑ Private P< Depth to Water Table A0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date___----------------) No;K New Construction: Yes ❑ No X FHA/VA: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public seweris 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---6- 1____Distance from foundation._.s6d........Distance to nearest lot line__.30' �. Number of lines-------•_____- �) _______-____Length of each line_______._/OQ_'_...____-Width of trench__-__.____.. "•.--_--_--_ Old cLAA, Type of filter material-__ ___Depth of filter material _______,lQ___'_--Total length______________________ -IM-_--_-_. p Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- El Number of pits----------------------Lining material-____ __ _-__ '_.;Size: Diameter-----------------------De-pt _----------------.------------ Cesspool: ____- ____Cesspool: Distance from nearest well-----------------Distance from foundation-------.------------Lining material--------,___-_-____-__-____.-..._.. ❑ Size: Diameter----_-----------------------------Depth_-----------------------------------------------._Liquid Capacity............................gals. G Privy- Distance from nearest well__.----------------------------------------------Distance from nearesf building------------------------------------------ � 11 Distance to nearest lot line------ ---------------------------- Remodeling and/or repairing describe :______.. --------------•--•-----•-----------------------------------------------------------------•--------------------- ----------------------------------------------------------------------------------------------------------------------•-------------.-------------.-•----------------------- --------------------------------_--------------- • ---------.--------------------------------------------------------------------------------------------------------- ------------------------------•---------------------------------.----------------------- --------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A� ordinances, State laws, and rules and regulatii3ns of the San Joaquin Local Health District. �� ^-'�-- (Signed) -Owner and/or Contractor) - ------------- ------ ----------------------------------------- (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 APPLICATIONACCEPTED BY--------------------------------------------------- ------------------------------------------- DATE-------------------------------- REVIEWEDBY----------------------------------------------------------------- _----------- = r r DATE------- BUILDING PERMIT ISSUED ------------ -------------—----- - '> ------- ----- DATE-------------------_------ Alterations and/or recommendations:----------------------- ------------------------------------------------------_..---------------------•----------------------•-•---------------- ---------------------------------------------------------------------------- -------------------------------------•--------------------••_,-..------------------------------------------------------------•------------------- ------------------------------------------------------------------------------------------------------------------------------•--•---------•-------••--•--------••---------••-------•--•------•-------------•----•-----•--••. -----------------------_---------- ....................... •-------- ------ _ FINAL INSPECTION BY----- -- ...... e!--- :- '-----! '� 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 B-S9 3M 3-'63 F.P.CD. .