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'AOR OFFICE USE: - L ____ _-- APPLICATION FOR SANITATION PERMIT Permit No. .1 / _.. - - (Complete in Duplicate) ---------- ------------- This Permit Expires 1 Year From Date Issued Date Issued ?. 6 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. 54�9�.D JOB ADDRESS AND LOCATION = `"'` = Owner's Name-------- Phone----------------------------------- Address --------�n-----------------`----------------•---•-----------------------•---- ------------------------------------------------------------------------------------------------------- Contractor's Name •�---- -----------------------------------_ --- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of living units:_)----- Number of bedrooms 77---._ Number of baths ___I____ Lot size .7�5_.i____..; _._/.. .` ________________ Water Supply: Public system ?q Community system ❑ Private ❑ Depth to Water Table6-_a_ ft. Characfer of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe a Hardpan ❑ Previous Application Made: (If yes,date--------------- ----) NoX New Construction: Yes ❑ No FHA/VA: Yes ❑ NoZ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest weld_________________Distance from foundation-------------------:Material----------------------._-______________.______.. No. of compartments------------ ------- Size--------------------------------Liquid depth--------------------- Ca acit 1 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 material-----------------------Total length-------.---._._.__.----------------------- Seepage Pit: Distance to nearest well_` Distance from fo dation_____ _ _..Distance to nearest lot line__. _.__ 00 Number of pits_____._._-------------Lining material--5._._ ize: Diameter------ sr-' . _..Depth--------------------------------- Cesspool: ____..__. --_________--__Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-------------------------------------- ❑ Size: Diameter---------- _ = �____.__Depth -r ------------------------------------------Liquid Capacity----------------------------gals. Priv Distance from nearest well_____._________ ._ _. Privy: __________________________Distance from nearest building---__--___._____________ ❑ Distance to nearest lot line.--------- ------------------------------- ---------------------------------------------- ------------ Remodeling and/or repairing (describe):--------A-1t ------ - ----- -- -- -- ---------------------------- •------•- 9 -------------------------------------•-----------------•---------------------------------------------------------------------------- ------------------------------------------------•----------------------------- ------ ---... O ---------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------- .----•------------------------------ ---------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------------------- ---- ---- - 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. (Signed)----------------- ?---. ------ Cr—..------------ -- -----------------------------------------------------------------------( weer and/or Contractor) BY:-------------------[ _.. ---------(Title)-------- ` (Plot plan, showing size:of lot, location of sys+em in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY----- - ` --------a'_--' ----- -------------------- --------------------------� �� - -------------------------------- DATE ---- -- ------------------------ REVIEWEDBY------------- --------- -- -- ------------------------------------------------------------------------------ DATE--------------------------------- --------------- a BUILDING PERMIT ISSUED- =-------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------- - -- - ----------------------------------------------_" _ -- --------------- - 1 ------------- ------••---------- I r4 -------------------------------------------------------------------------- - ----- -------------------------- I! c -----------------------------------------=-----------•----------- -•-- ----------------------------------------------------- -- ------------ -------- --------------------- -------------- ------- ------------- ------- t w —� ob t FINAL INSPECTION BY:. -------- ------- ------------ 6-ate-1-7-------------------- ------- --------- - ------------------------------ 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 E5 9 REVISED S-S9 3M 3-'63 F.P.00.