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FOR OFFICE USE: ------------ ----------------- - - -�G- ---------- -- - - APPLICATION FOR SANITATION PERMIT Permit No. .._� :. . _.` ... ------------------------------- ------ --, (Complete in Duplicate) -- -- --.--. Date Issued _ ___Y__ ___________ 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 O IONZZ ----------------------------------------------------------------------- Z -- - � - Owner's Name--- ---•••- --- • r --------------- ------------------------------ ------ Phone-----•----------------------- Address - .... _--- ------- ----- ----- ---------------------•-------------------------------•-------------------- Contractor's Name---- ----------------- --------------------------- - - ------ Phone---------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Number of bedrooms __. Number of baths ___ Lot size _______________ _ _ lfb Z!_0 Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table_oft_ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Ilf 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 ,an Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------._____________- No. of compartments--------------------------Size-------------------------------_Liqu `depth--------------------------Capacity-•------1--�-- D+'sposa],Field: Distance from nearest well-----.............Distance from foundation------------------Distance to nearest lot line_________________ Number of lines-----I______ Length of each line__-U---_________________Width of trent _ T e of filter materiaL _�C._ _______De Depth of filter material___ _: _ `` Total length ----------------------- Ypp lr-- -------- g ---------------------------------- f Seepage Pit: Distance to nearest well__ ______________Distance from foundation/O___-----------Distance to nearest lot line___J____ _ to 2)^�Number of pits ___I--------_-------Lining material---- �A_cl__-Size: Diameter___ __-___-___--Depth__ _ ___--__-________ Cesspool: Distance from nearest well-----------------Distance from foundation------ -------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth------ --------------------------- ----------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well--------------------------------------------_----Distance from nearest building------------------------------------------ '1 ❑ Distance to nearest lot line--------------------------------------------------------------.....--------------------'------ ---- --------------------------------------- 3 1000. Remodelingand/or repairing (describe)-------- ----------------------------- --------------------•-------------------------------------•------------------------------••------------------------ --------------------------------------•-------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------ ------------------•--------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------- - - I hereby certify that I have prepared this plica on and at the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulat' ns 0f a San aquin Local Health District. (Signed)----------------------------------- ------------------ ---- / ------ ------------------------------------------------------------------------(Owner and/or Contractor) By:---------------------- ---------- ..............f-- ---F- ------------ ;------------------------------------ (Title} (Plot plan, showing size of lot, loc ion of ste in relation to wells, buildings, etc., can be placed•on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---------- ------------------ ---------- ---------------------------------- DATE------- 3------------------------- REVIEWED BY-------------------------------------------------------------- = DATE ---•---- ------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------- ----- Alterationsand/or recommendations:------- --- -------- ------------- ---------------------------------------------------•--•------------------------------------•-----•------------- -----------------------------•---------------------------------------------- L --------. --------•------------------------------- A, -- ---- -------------------------------- ---------------------------------i/ ----- ----------- ---------------------------------------------------: --------------------------------------------------------- --------------------- ---------- FINAL INSPECTION BY:_._.C1.......5 -�_ -- ---------------------- Date---- SAN ate--- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Na:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3•'63 F.P.DD.