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FOR OFFICE USE: --------------------------------------------------------- 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 p,�f�it to construct and install the work herein described. This application is made in compliance with County Ordinan No. 549. Lo P JOB ADDRESS AND CATION L -- -- --- I`7 ------------------------------------------------- Owner's Name--- ----- - -- - ----- - -- ------ ------ ------------ Phone------------------------------------ 4( z Address `- -----••- ------------- --------- ------ ------ --- -- Contractor's Name__. ..-'.. --- -.---- ---- d`---�'�---- - ------- ---- ---- Phone----------------------------------- Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/--- Number of bedrooms- Number baths I_._ Lot size _____ ------ _. _ ____________________ Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Tabl ft. Character of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam El Clay Loam[Clay ❑ Adobe ❑ Hardpan ❑ I Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {n} (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Mater:al-----------------------------___-_._.._.________- No. of com artments--------------------------Size----------------------------_---Li Liquid de th---,_---------------__ 1 ❑ p � q P.' ----Capac�tY--------------�.;/ Dispos field: Distance from nearest well____�U...-Distance from foundation___._/ Distance to nearest loot lire_________________ Number of sines______.____-___�_ -_ Length of each line______�ra O_"--- -- ----Width of trench_____________ Type of filter material__�rFJ. +---Depth of filter material-----/__ ___._Total length__________ _ _______________________ Seepage Pit: Distance to nearest wel3----------------------Distance from foundation--------------------Distance to nearest lot line__-_-___.__.__-._ ❑ Number of pits------ ---------------Lining material-----------------------Size: Diameter----------------- Depth--------------------------------- C 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 re ing (describe -------------------- N---------------------------------•------------------•------------ ------•-- =---�- ---- --- ----�-- .- - � -- ------------------------------------------------------------------------------------------------------------------- -- ------------------------------------------------------------------------------------------------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, d rules and regulations a San Joaquin Local Health District. � ' (Signed)---------- ---------------------- --- ------ -- - ------------------------------------------------------.....�or Contractor) ¢ ` ----- Title---------------------------------------- --- - - ------------- By:------- -- --- ------------------------------------ ---- --- -- (Plot plan, showing tixe of lot, location of system in relation to w s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----------------------------------------------------------- DATE r - r G -- ---------------- REVIEWEDBY-------•--------------------------------------- -----------------------------------------------------•----- ----•- DATE------------------------------------- --------------I--- �? . BUILDING PERMIT ISSUED---------------------------------------------'-- ------ DATE------------------------------ ------------------------------ Alterations ----- ----------------------Alterations and/or recommendations:---------------------------------------T---•----------------------------------------------------------------•------------------------------------------------- ----•-•---------------------•--------------------•-----------------•- ---------------- --------------------------------- ------------------------------------••----------------------------------------------------------- ---------------------------•---------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------• ----------•----------------------------------- FINAt INSPECTION BY:____f. r: ---------------- Date__'_` .~ _ _ ---------- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205'West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED B-59 3M 3-'63 F.F,CC. 1