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FOR OFFICE USE: / APPLICATION FOR SANITATION PERMIT Permit --------------------------------------------------------- H (Complete in Duplicate), i -----------------------------------------.-__ This Permit Expires 1 Year From Date Issued Vats Issued .. _rP __ __ 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 complia ce with County Ordinance No. 549. 25 —('70—Oy Les b� ter-,� - � r" JOB ADDRESS AN OCATION _ f -__.lf ______ -- --- --- ---- - � ---------- `�'�" a r Owner's Name --- - Phone---------•-------------------------- r Address------ ----- - � -- ---- ---,- ---------- -----------------------------------•-------------------••--------- o; � e Contractor's Name__.------- ¢ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: _I____ Number of bedrooms _ umber of aths Y--- Lot size ___________________________ ________-________-___ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay [Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New. Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE;OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -� -R-.-� - — - Septic Tank: Distance from nearest well-----------------Distance from foundation_____--------------------Material____-____-------_________-___-________-_-_____. --- Liquid depth---------- ------ --------Capacity--------------------- , ❑ No. of compartments------------------------.Size-----•------:--`_-----_ -- r Disposa field: Distance from nearest well__"!2__-_Distance from foundation-----fr(,�---------Distance to nearest lot line._..______. Number of lines----------l______ ___ __ _____Length of each line____ _-----__-____-Width of trench_-__.ems_°__-____-___-_________ Type of filter material._-___. i__ r__ __Depth of filter material`-____ �__ ____-Total length______a, ,C------____________________ Seepage Pit: DistEl Numance t nesrest well ___--in-n --Daistaal e from fou d Ze:nDiameter--- Distance toDnepat st lot line --___----__jfi Number Cesspool: Distance from nearest well________ - _ :_Distance from-foundafiion--------- ---------Lining material --------------------- -- ❑ Size: Diameter--------------------------------------Depth----------------------# ----------------- - - -Liquid Capacity----------------------------gals. p ___1.. Privy: Distance from nearest well----------------------------------------------i___ isfance from nearest building----- ------------------------------------- ❑ Distance to nearest lot line------ ------------------------------------- -----------------------•--------------------------------------------------------------------- IO Q Remodelingand/or repairing (describe)=-------------------------------------- ---------------------------------------------------------•------------------------------------------------------- ---------------•----•---------------- •------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------11----------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------• --------------------------------•---------------------------------------------------- ------ Via ----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------•-------•--------------------------------- ---- Q+ 1 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)--------------------------------- -- - --- -- --- - --------------------------------------- -----------------------------------------mrd/or Contractor) By:------------ •-------- - ------- - -- - -- --- --- ----------•-----------------------------------(Title)---------- --- --------------- -------------- (Plot plan, showing size of lot, location of system in re tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - -------------------------------------------------------- DATE-- 6 -------------------------------- REVIEWEDBY------------------------ -------------------- -------------- ---------- ------------------------------------- -------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------- -----------------------------------------------•--------------------------------------• DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------------- ----------------------------------------------•---------------•----------------•------------------------------ -------------------------- ---------------------------I--------------------------------------------------------------------------------------- ----------- ----------------------------------------------------------- ------------------------------------------------------------------------------------- I----------------------------------------------- ---------------------- - FINAL INSPECTION BY:_�.�._ _! ?A --------------------- Date__.---�^�-�f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nasallon Avo, 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3•'63 r-P.CC.