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FOR OFFICE USE: t --------------------------------------------------------- l �r _________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ----------------------- ---------------------------- -- (Complete in Duplicate) / Date issued ------------------------.....-------------.---------- _ _ This Permit Expires 1 Year From 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 ------ d d ---------------------------------- --- ------ ------------------------------ Phone------------------------------------ Add --------- -- ------------ ----- a Contractor's Name--- '. �- -------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __/-___ Number of bedrooms _.,—Number f baths Lot size _. -- _________________ Water Supply: Public system C1 Community system ❑ Private Depth o Water Table __._____ ft. Characfe� of soil to a depth of 3 feet: Sand E] 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 sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation___-----------------Material______._______-____-____-_____------___.____.- ❑ No. of compartments----- --------------------Size---------------------------- ---Liquid depth--------------------------Capacity---------------------- � r Dispos Field: Distance from nearest well_�D-�-_-._Distance from foundation.--/.U__________-Distance to nearest lot Number of Lines_________ Length of each line___`4� --/------------Width of trench.--- ------ t_ _{_ r-1Type of filter material__� __ ,_______Depth of filter matenal___ � ___________.To#al length Seepage :Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-________.___.. ❑ Number of pits----------------------Lining material---------- ------------Size: Diameter-----------------------Depth--------------------------------- h Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______.---_._______-______________-_. =� ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid Capacity----------------------------gals.' Privy: y Distance from nearest well---------------------------------------------------Distance from nearest building __--_. ------------------------------ -----------------•----------------------- N n ❑ Distance to nearest lot line_.------------------------------- ------- --------- -------- 1 Remodeling and/or repairing (describe):--------- -----=---- ------------ ----------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------•--------------------------- ----------------------------------------------------------------------------------------------------------------------------------- Y - _____________________________________________________•_______.____________________________________________--_________________________________________________-_-_____________-________________._..__________._____.___________ I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Set* laws, and rule and regulations of the Sa Joaquin Local Health Dis+ric+. (Signed--------- - ---(�------ d/or Contractor] 13 ----------------- �1l1 6t- R- --�-� (Plot plan, showing size of to+, location of system to relat n to wells buildings, (Title)_____________�'__________________----_______________ _______ p g y gs, etc., can be placed on rev ers eaide). FOR DEPARTMENT USE ONLY �i• ,• f= APPLICATION ACCEPTED BY_ r-� ----------------- D T r G . REVIEWED BY------ ; Oro• �� �4r¢• D if i------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------------='SDA ' Alterations and/or recommendaf ions:--------------------------------------------------------------------------------------------- ----------------=------------ -------------------•---------------------------------- -------------------------------- i+ ----------------- ;---------------------------------------------------------- .� ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ FINAL INSPECTION BY: �•� 'f�r Date ' f SAN JOAQUIN LOCAL HEALTH DISTRICT', 1601 E.ffaz•lton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 55 9 REVISED 9.59 31A 3-'63 F.P.CC-