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3 APPLICATION FOR SANITATION PERMIT Permit No ................_------- Q(Complete in Duplicate) )4 -1 Date Issued ._.__._....--.---- Application is hereby made to{the San Joaquin Local Health District for a permit to construct and install the work herein clescrib, ed. This application is made, incompliance with County Ordinance No. 549. 1 JOB ADDRESS ANDey CATs►___ •,,i�--- ------ Phone ---------------------••------•------ I Owners Name t-- - t Address__ �-`- ---•--------- --•--• ----------- ---Phone...----•---------_---- ----•- -- -- - ------ --- Contractors Name-------------------- -- t----- - - --- r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer: Court ❑ Motel ❑. Other ❑ i a i i >- bedrooms of living units: _____ Number of bedrooms -�_-_ Number of baths :y-_ Lot sizelU__________________ ------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth"fo Water Table----__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam e Clay Loam ❑ Clay [❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ 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 ---Z 2 ---------.Material_______ % �� !;?i' Liquid depth------------ Capacity.. / --�©-- �i71 No. of compartments---------------- ---%----Size---- -- - Disposal Field: Distance from nearest well -_52) -_----Distance from foundation -r --f_0 --------Distance to nearest lot line -_-b---------- pQ I' Number of lines -------3------------ - Length of each line--��y--�U1-}-4-Width of trench.-•--��- _------------•-- (/1 Type of filter material--,�_= � -Depth of filter material--- '!--____-_Total length ------- z;7-�_________________ f Seepage Pit: Distance to nearest well ------------------------ Distance from foundation ---------------- ---.Distance to nearest lot line ---------- ....... ❑ dumber 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 ------------------------- ._____----,---.-. ❑ Distance to nearest lot line -------"--= - --------------=----------------------•------------------------------•------------------------------------------- ------ Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------------•----•-----------------------•--•-------- -----•--------=-•-•-----------------------------------------------•---------------•------------------------------•-----------••------------------------- --------------------- 4 - ------------------------------------------- ---------------------------•---------- y 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, an ules an regulatio 's of the San Joaquin Local Health District. �3----------- -----------------------------------------(Owner an r Contractor (Signed)---------------- ' .---------............ ----) y l------- ----•-------- -(Title)---••---------------------------------- - ---------------------- iBy:------------•--------------------------- - -------------------- --------------------- (Plot plan, showing size of lot, location of system in ,relation to wells, buildings, etc., can be placed on reverse side). F -FOR DEPARTMENT USE ONLY t ---------------- DATE-- �- APPLICATION ACCEPTED BY_____ __ _ ___ __ ___ -� 4•_. ___. REVIEWEDBY--------------------------- ----------------- ----- ----------=------------------------------------ --------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------- DATE ------------------------------------------------------------- Alterations and/or recommendations-------------•--------------------=-------------------------------- -...----------•------------•-•------------------------------------•--------------•--------- Yl_ f'---------------------------------------------------------•-----------••----------• -•--- f -----------------------•--------- +1 -------------------------------------------------------------------------------------------------------------------------------------------------=----- =- - t . FINAL INSPECTION BY ----------- � ----------- ---- -------- -- Date- -- --------------------------- r ;� ------ - SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California F f5 -9-2M , Revised 1-57 F.P.CA.