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FOR OFFICE USE- ----------- ------ --- ----------------- 1-1 ------------- -------------- --------- ------------- -----'--_.__.-----.____.--__________ ----------------- APPLICATION FOR SANITATION PERMIT Permit No..1... -------------------------------------------------------- (Complete in Duplicatel This Permit Ex fres 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. JOB ADDRESS AND LOCATION--- Owner's OCATION-- Owner's Name ------`i,�-r , ----------------------------------------------------------------------------- Address-------•---•-------------- -----------•--•----------..------------------------------•----------••------•----•--------•--- = 7- Contractor's Name -------- -- - - -•--- -••-------•-•----------------------•---•------------•--------------••-•-•------•-----. Phone ........ ........ ..-------•--------- Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I_____ Number of bedrooms __3__ Number of baths ___- L Lot size __-_�%-X-_��---------------- Water Supply: Public system EVCommunity system ❑ Private ❑ Depth to Water Table �j'�5 ft• Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q— Hardpan ❑ Previous Application Made: (If yes, date ---- ----- ----------- ) No ®' New Construction: Yes 2 --No ❑ FHA/VA: Yes ❑ No M— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well ------- Distance from foundation.__Za�e___. _Material-- `-._----------------------- [?' No. of compartments ----- �------------- --- Size ----- -------Liquid depth..--�-------------- Capacity ao c Disposal Field: Distance from nearest well_.P___.__.._Distance from foundation ------------- Distance to nearest lot line_l47__ ....... [ ' Number of lines --------------- o�---------------Length of each line ------ � `--------------Width of trench ---- r�S'el------------------- Type of filter material -------- Depth of filter material____ l-8.` ........... Total length ...... lD--------------- _----------- Seepage Pit: Distance to nearest we€l_LTb___----------- Distance from foundation _.......... Distance to nearest lot line___3—..i ®_ Number of pits ---- .off -------------Lining material..0—KoCt------Size: Diameter .... 4�?-y--------- Depth -------- / -'-•--------------- 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 fdescribe):------------------------------------------------------------- - ------------------- ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------• ------------------------------------------------- --------------------------- --------------------- --------------------------------------------------------------------------------------------------------•--------------•---------------------------------------------•--------------- ------------------------ 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)------------------------------------------ ---------- - ------------ (Owner and/or Contractor) --- ---- --- -- - - ---- -------- ----------------- By:----------------------------------------- - - -- (Title) ------------------ (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 APPLICATION ACCEPTED BY_:;�- •-----------•--------- DATE-----•--'S!-La- -6--------------- REVIEWEDBY ---------------------------- --------- v--------------------------------------------------------------- _-------------- DATE ---------------------_-- BUILDING PERMIT ISSUED---•---------------------------------------------------------- ------------------_-.---------------- DATE- ------------------------------------------- Alterations and/or recommendations:---------------------------------------------------_-__ ----------------- ---•----------------------------•-------------------------------------••------------ --------------------------------------------------------------- - FINAL INSPECTION BY: - -- - --- ----------- ------ Date. Iy SAN JOAQUIN LOCAL HEALTH DISTRICT f 30 South American Street 300 West Oak Street 124 Sycamore Street 205 Wast 9+h Street Stockton, California L041 1, California Manteca, California Tracy, California EC -9 REVISED H-59 r•P.DD. 2M 6.61