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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .__ --- ------ ----------------------------------------- --------------- (Complete in Duplicate) 6 ____________________ 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 Ordina o. 549. 3�0 el �r JOB ADDRESS AND OCATION• /-------- o- Owner's Name Phone Address----------13,6,6-------�------ x* �-------- ------------------ ------------------------------------------------------------- - Contractor's Name-------------- -------- Phone-------------------------_ Installation will serve: ResidenceApartment Ho e ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Numb&'of-Uedroorris __-Number-of baths __/__ Lot size _:_.__. _____________ Water Supply: Public system ❑ Community system ❑ Private Z Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [( Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date___________________J No ❑ New Construction-TYes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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--------------------Material___._______________.____________________-__t. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity...-------------------- Dispos Field: Distance from nearest well ..__' �_--_.-Distance from-foundation.___./!'----------Distance to nearest lot line._.5........: Number of -lines--------------�__�^}___ Length of each line___________ ---------Width of trench---------- Type of filter material------ of filter material__________/ --------Total length---------/4_C-____________________ +6 Seepage Pit: Distance to nearest well----------------------Distance from foundation-------•------------Distance to nearest lot line______________.._ G ❑ Number of pits----------------------Lining material------------- -----.-Size: Diameter------•---.-------------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--------------------------------------.._. -0 ❑ Distance to nearest lot line------------------------------------- ------------------------------------------------------------------------------------------------------ �. Remodeling and/or repairing (describe): -----------------------•---•-•-•----------------••--------------------•------------------ ----------------------------------------------------------------------------1------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------ I ---------------------------------------------------------------------------------------•----•------------------------------------------- I hereby certify th ve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law&Af and rut s and regulatioAanoaquin Local Health District. (Signed)----------------- ------ --- -- ------ - ------------------------ --------------------------------------- d/or Contractor) � " , ,.�—.�emner �J'By:-__-------- irl.�z✓r--- ' ---- -------------------------------(Title)------------------------------ ---- -- --------- (Plot plan, showinlot, location of systeells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- DATE I 00-_�7---------- --------------------------------- REVIEWEDBY------------------------------------- ------------- - ---------- DATE ------------------- BUILDINGPERMIT ISSUED--------------------------------+ ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------•------------•-----------•----------------•-•------••----•-----------....---------------------------- ---------------------------•---------------------------------- ---------------------------------------------�--------------------------------------------------------------------------------- ------ ---------- --------------------------- ------ --------••-----------•------------------------------------------------------------------I------------------------------------------------•------------------•--------------- ------------------------------ -------------- ------------ --- -------------------------------------------------------------------------------------------------------•---•------------------------------•-------.------------------ ----•--------------------------------------------------- FINAL INSPECTION BY:_ 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 CS 9 REVISED 8-59 3M 3-'63 F.P.120.