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FOR OFFICE USE: ---------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 1 --- ------------------------------------ ------ --I-------- (Complete in Duplicate) Date Issued___ ....... This Permit Expires 1 Year From Date Issued - rd 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. �J JOB ADDRESS AND LOCATION-I--- --• _ �,c -------------- Owner's =QOwner's Name----- - -i^---- --------------- -- Phone--------------------------------- Address----------- I Contractor's Name :L"cs = -------------- Phone-_------------------------------- Installation -- -Installation will serve: Residence 0/ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms __ __._ Number of baths I--- Lot size _____ --------------------------------- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ZHardpan ❑ 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material---------------------------------------,-_____- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity---------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___________._____ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------•--------------•--- Type of filter material-------------------------Depth of filter material-----------------------' length------------------------------------------ / 5. / _ Seeps: __ Distance to nearest well----,�_�.e__/ L]_ __'f_Distance from foundation------! ___tr Distance to nearest lot)ne----_____ _ [� Number of pits-------- ------------Lining material----- .-.-----Size- [ trte4e _- .X_.-�- --Depth--- ---------•:-------------- Cesspool: Distance from nearest wel€-----------------Distance from foundation___-_-- ---------Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-_..---------------------------------------------Distance from nearest building___________________-____________-____-_-_. ❑ Distance to nearest lot line-------- ------------------- --- - ---------------------------------------------------------------------------------------------------- ----- Remodeling and/or repairing (describe)________ ___ ______________ -------------------------------------------------------------------------- t -----------------------------------------------------------------------------------------------•----._.---- -- ---------' -/...----- 1 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) ------------ ------------- ------------- -------- -- ------------------------ or Contractor By-------- elation --------{-------------------------------------------_(Title)---------- ---------------------- --- - --- (Piot plan, showing size of lot, location of system in to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- ---------------------------------------- DATE--- __ _" -__-______. REVIEWEDBY-------------------------i_----- --------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-----------------------------------------------------------••--------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:---------- -------.------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------•------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- -------------------------------------------------------------------------------- - -------------- --------------------------------------------------••---------------------------- ------------------ ----------------- FINAL INSPECTION BY%.1' �"'F:: _ '.t.;�,---------------- Date -�_ ._` . SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.tlla:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California g ES 9 REVISED 8-S9 3m 3-•63 r.p.CD.