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FOR OFFICE USE: ----------- -_-----_----------------------------------- ------------- APPLICATION FOR SANITATION PERMIT Permit No. ___._..... _ ... ------------------a_-------------------- ---- ------------ (Conplete in Duplicate) ------------- ----- This Permit Expires 1 Year From.Date Issued Date Issued ------ A d�-0 2- Appljcation is hereby made to the San Joaquin Local Health District for a permit to construct and instal the work herein described. 'This application is made in complian-pceitf�r Co upnty Ordinance N6. 549./--Z B'ADDRFSS-AN13LOCATIO�------- " `-- --- ----------------------- '} � ----- - , — -r----- - -------------- ---- ------- ---- phone----••--••--------------•----------- Owner's Name F:Address ----------- e d --------------------------------------------------- Contractor's - ---- --------------------- -------- Contractor's Name__________ } -----`--- •------- ----a------------------------------•--- ------------------ �hone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer- Court ❑ Motel ❑ Other ❑ Number of livingunits: __ .____ Number of bedrooms __ -- ..�_. Number f baths -_�.-_ Lot size __ _�-.e—�-�- ______________ Water Supply: Public system ❑ Community system E] Private Depth to Water Table t ft, i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cl ay`boam Clay.❑ Adobe ❑ HardpanET 1, -' - _ ; Previous Application Made: (If yes,dote-----4r--._.___ _) No �] New Construction! Yes 0 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----------------------- Dispos Field: Distance from nearest well....`4 ` _�__Distance from foundation------ ___.Distance to nearest lot line___C7__f__, r Number of lines______________f_ _ _..___..____ Length of each line______1_Q0--------------Width of trench------- _,_-__---___________ 0 Type of filter material___ --------Depth of filter material__---�r?---.__._Total length--------ld_Q____ ------------------- Seepage Pit: Distance to nearest well------_---------------Distance from foundation--------------------Distance to nearest lot line---------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------.Depth-------------------------------- Cesspool: T- Distance from nearest well-----------------Distance from foundation-----------.------- Lining material__._..---_-----__-..___.___.______ -..� ❑ Size: Diameter------------------------- ----------Depth------------ -------------------- ------------------Liquid Cap acity----------------------------gals, 'Privy: , + Distance from nearest well_____________ _____________________________Distance from nearest building_,,_---___.__.________:_____.__._.___.__. [] Disfiance•to nearest lot line- ------------------------------------------- -------------------------•--------------- �J Remodeling and/or repairing (describe):........ 1--.� !-��.:_% _ _ ____ __ _ -----------------------•---•-•----------------------------------------•--------•------------------------------------- ------------------------------------------------ -------------------- ----------------------------------r---------------------•----------------------------------------------------------------------------------------------------------------------------- ___________________________________________________________________________________________________________________________________________________________________________________________________________ __________________ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I4ws, and rules and 'gulations of the San Joaqui Local Health District. (Signed) !f-r --------------- /or Contractor) Y•--•----- f - __ (T* -------------------------------- ----- plan, showing size of lot, location of system in relation to wells, buildings,'etc., can be'placed on reverse sidi)'.T FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ------------- REVIEWEDBY--------------------------------------------------------------------------- ---------------------------------------------- DATE----------------------- BUILDING PERMIT ISSUED---------- ------------------------------------------------------------------------------------------ DATE--- Alterations and/or recommendations:----------------------------------------------- -----------------------•-----------------------•-•----------.-------------------------------------------------- ----------------•-•------------•--------------------•--- ---------------------------------------- - ---------------------------------------------------------------------•------------------------------------------------•-- FINAL INSPECTION BYi:�`"�`=°��' ' bate l 3- ------ ----------- ------------- -------------- 6.� SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazallon Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 5-59 31A 3-'63 F.F.Cd. 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