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vrri =3�G�� `f---------------- 3 --------------- --------- -- - --------------------- ----- APPLICATION FOR SANITATION PERMIT Permit No. --. ..- _----_ --- --- ----- -------------------------------------------- - - - {Complete in Duplicate) � y This Permit Exloires ] Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a p This application is made in compliance with County Ordinance No. 549. ermit to construct and install the work herein described. JOB ADDRESS AND LOCATION_ - ----------- ------ -------------- Owner's Name.---------------------- - ----- -•--•------• 1 Address -------------- ------------- ---- Phone. -------•------ -------------------- -------------•-------------- - Contractor's Name_ �� ------------•--------- =----- `} Phone. Installation will serve: Residence r (� Apartment House ❑ Commercial E] ' Trailer Court E] Motel ❑ Otlier Number of living units: "! ❑ --- Number of bedrooms -Z--- Number of baths ... Lotlsize 7S """- ..... "" Water Supply; Public system Community system ❑ Private ❑ Depth to Water Table j65?- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam r } Y ❑ Clay Loam ❑ Clay ❑ Adobe g Hardpan [] Previous Application Made: 11f yes,date-------- -----------] No 'g New Construction: Yes El No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: IV (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank Distance from nearest well • ""Distance from foundation....................Material El _."__._"""--"___." ` No. of compartments---------------------------Size---------------------- - -------------------------- Liquid depth ------ ------Capacity----------------------- Disposal Fiel Distance from nearest well � - �X--_-Distance from foundation-"_"Jo!"-""_Distance to nearest lot line_""".,5:-`""•_ ® �"S Number of lines----------- __---- Length of each line"--" "" '- .35 -----.Width of trench 3 Type of filter material__!C�_ __/C,__ Depth of filter material _ " Total length - -------'---- �= ---- Seepage Pit: Distance to nearest well ___Distance from foundation---_-1Q2 ` --".Distance to nearest lot line" i F ® Number of pits--------,-----------Lining material_aC4fC__-Size: Diameter-------9 4-----Depth------ �. i --- ----------- Cesspool: Distance from nearest well-----------------Distance from foundation ""_".Lining material_" ;.-"-. ❑ Size: Diameter. Depth --------------------- Iquid Capacity --------------------gals. V% Privy: Distance from nearest well------- :,_-------- `_>_" _-- --------------- ""Distance .from nearest building------------------ ❑ Distance to'nearest lot line--."- _"---" -""" --�— ---------------------- -------- I --------- Remodeling and/or repairing- (describe):------- ------------- _ ------- ---------------------- ------------ -----------------------------------------------------------------------------------------•------------------------- -----s k . ----------•-- ------------------------------------------------------•--------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed) By----------------- , (Owner and/or Contractor) ��-. - Own (Plot plan, showing size of lot, location of systerFr in re n o w ----- buildings, eft., can it e'lace . p on reverse side}. FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY.. �. ----- ------ DATE------' ' ��= _7 REVIEWED BY ----------- - ---- ---------------------- ------------- ---------------------- DATE---- ---------------------- UILDING PERMIT ISSUED----------------------------------------------------------------- ------- �-------------"---- Alterations and/or recomm to •---- -------------------------------------•- DATE----------- ----------------------- ---------- ---------- --------------------- --- :"_�"" --------------------------------------------------------------------------- ---- --------------- d t -------------------------------------------- ----------------- -----------•----------------------- --------------•- ------- -----------------------------------------------_---------------------•-------"...------•----_-•-_------_----_-- -----------------------•-------- ------------------- 4------------------------------------ F1NAL INSPECTION BY---------------- -< ------------------------ ------------ Date _. ..» ------------ ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hazetton Ave. 300 West Oak Street d . 124 Sycamore Street Stockton,California Lodi,California 205 West 9th Street Manteca,California ES 9 REVISED 8.59 3M 3-'63 F.F.CD. `racy,caiifornio