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FOR OFFICE USE: -----------------------------------------------------= -- APPLICATION FOR SANITATION PERMIT Permit No. --------------- -- ------------ -------- --------------- (Complete in Duplicate) -------------------------------------------- -- This Permit Expires 1 Year From Date Issued Date Issued a --��--- 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. k JOB ADDRESS AND LOCAT --- ------ , i C Owner's Name ___ �---- --- Phone Address -:... . ----- - - ---P f !��Contractor`s Name `'' �-- ------------------------ Phone Installation will serve: Residence [ Apartment House ❑ Commercial ❑ T'ra`iler Court ❑ Motel ❑ Other ❑ Number of living units: - /--- Number of•bedrooms _�/ Number of baths /-_.-. Lot size ____ ___________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Wafer Table ________ ff.- Character t:Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 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-3eweris available within 200 feet.) r Septic Tank: k Distance from nearest well_________________Distance from foundation--------------------Material--------___.___.._.___.___'___--.-_____--.-____. ❑ 41, No. of compartments--------------------------Size---------- `== "------ ---Liquid depth-------------- - ---------Capacity-=--------------------- Dispos Field: Distance-from nearest well...�1?------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-____ ..V_.___.__ _ g �_ __ ___________________ § � ;' �:,,_- � _Total length . Q_4�?_ � I Seepage Pit: Distance to nearest well_____ _______________D�isfance from foundation--------------------Distance to nearest lot line__.__.____.____-. [] Number of pits----------------------Lining material-----------------------Size: Diameter----.----------------- Depth•<._.--------------------------- Cesspool: '"Distance from nearest well__.--------------Distance from foundation--------------------Lining maferial___.____________-_______._._____..__. [J Size: fliameter- ------==---------=---- Depth-------------------------------------- -------------Liquid Capacity----------------------- gals. 'l .. - i Privy: Distance from nearest well----._----_-__.-_ 't 7- from nearest building_____.-_____--------______________.___. ❑ Distance to nearest lot line__ ___ ____ _____ _-_f----�-_ ' Remodeling and/or repairing {describe)------- ------------------------- ;------ --------- ------------------------------------ ---•---------------------------------------------------------•-------------- -------r"` T _. ---------------------------------------------------------------------------------------------------------•------------------------•--------------------------------------------------------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St aws, and rules and regulations of the San Joaquin Local Health District. (Sined).----- _ - __ --------------- 9 / r Contractor)� ��. o BY =----------- --�-------------•----(Title)------ ----------------=-------- - --- -- ----------- - (Plot plan, showing size of lot, location of sys in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY_- r .r �----'------------------------------------------------------- DATE-----�-��-�A�--------------------------- REVIEWED ---------------------- -REVIEWED BY- ----- --------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------•--------------- -------------- -------------- Alterationsand/or recommendations------------ ---------------------- -----------------------------------------------------------•--------------•-------••----------•--------------------------- -•-----•---- -------- --------------------------------------•-----------------------------------------------------------------------------------------------------------------------------------------•----------------------- --------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------•-------------------•---------------------------•------ -------------- --------------------------------------------------------------------------------------------------------------- ----------------------------- FINAL INSPECTION --------------------- Date..../- 4r— ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 west Oak Street 124 Sycarnore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-54 3M 3-'63 F.P.CO. i