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. .... ..... FOR OFFICE USE: �}---------- Permit No. --------------------- ----------------------------- I APPLICATION FOR SANITATION PERMIT - _ ------------------------ (Complete in Duplicate) Date Issued ----------- This Permit Ex ires 1 Year From Date Issued --- ------- ------ ----------------- an Joaquin Local Health District for a permit to constru t and install the w Application is hereby made to the Sork herein described. This application is ade in compliance with County Or e No. 9. n CATION_ JOB ADDRESS N e' Pone ... ----•---•----- ------------- Owner's Name--- --- - -- ---- -- -• ------ ---------------- e -- -- ---•--- Address-------------- -•• --- Contractor's Name___________ __ _ - ••---------• Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other Number of living units: ___ ___ Number of bedrooms _ /_ Number of baths ---�- Lot size Water Supply: Public system " 1ommunity system ❑ private ❑ Depth to Water Table . af+• obe Hardpan El Character of soil to a depth of 3 feet: Sand E] Gravel [I - Sandy Loam [IClay Loam ElClay ❑FHA/VA: Yes C] No El Previous Application Made: (If yes!date___-____.-.........1 No F1 New Construction: Yes El TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if publics wer is available within 200 feet.) Septic Tank: Distance from nearest we1L Distance from found +on CapautY ppV Size__ _JL _ -----Liquid depth__ ----- ---- f� No. of compartments-------- - r' +5--.----- Disposal Fie4cl.-. Distance from near st well - Distance from foundation__ ___Distance to nearest lot line-/- i DQ Number of line s----- -------------------Length of each line___- -- ------`----Width of trench-----s2-55 ----- -------------- filter ----------- -----._Total length-------------•---=- --•----• Type of filter rrmaterial4 �- -Depth of filter matenaL______1- - I Seepage Pit: Distance to nearest well-_____-_"___:- ___.Distance from foundation-----_--------------Distance to nearest lot line------------------ Seepage material. Size: Diameter - Depth ❑ Number of pits--------------- ---- g - 1 0 Cesspool: Distance frominearest well_________________Distance from foundation----- materia__._____--..------------------ al-- ---be Depth -------- -------------------------------------- Distance -------------- ------- ------- Liquid Capaci+Y-----.------------------`--9 ❑ Size: Diameter-----.- ------------------------- P Q. -_-.-Distance from nearest building------------------------------=----------- ro Privy: Distance from near well--. ------------------------------------ _-__ Distance to nearest lot line---------- ------------------------------------- El t ---------------------------------------------.. ----- Remode4ing and/or repairing (des �c------------------ ---- ,. -`--=Q_ -- /� --- 7 -------------- ----- ----------------- ------------------- ------ ------- ---------------•------------- I hereby c ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, e`I and rule and regulations of the San J Local He th District. i J ( r Contractor) g --I -- ---- ---------- - lrtl By:---------------------------- - -------- e) . (Plot plan, showing size of lot, location of system in relation to ells, buildings, tc., can.be placed on reverse side). :) O DEPARTMENT USE ONLY DATE ---- . ---------- -------------- DATE---- / - R APPLICATION ACCEPTED BY---------- ---- ------ --- ........... --- --.------ REVIEWEDBY--------------------------------- ------------ ------- --------- DATE------------------------- BUILDING PERMIT ISSUED--------_ ----------- ------------------------------------- _ ,. -------- -- ---- ---------------- - Alterations and/or recommend attons:.______________________________________ - i ------------------- ------------------- -------•----- -C•-------------- -- ---------------- ------- Date---- ---- � ----------------------------- � FINAL INSPECTION BY:_-_Ile___'-.--- - -- - �--- -�- ��- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:slton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Lodi,California Manteca,California Tracy,California Stockton,California ES 9 REVISED a-s9 3M 3•'63 F.P.00.