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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT yrs Permit No. _---_1----__--`- •- ------------------- ---------------------- ------------- (Complete in Duplicate) �1F f •� -------------------- --------------------- -- ----- -- is Kermit Expires ] Year From Date ssued 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. JOS ADDRESS AND VLOCATON/ -•------ ---- ------------•--------•--- ------ '-------• •-- 1_.Owner's Name 1 --- --------1- PhwAddress_... .e'`'V s ... / -~ + -----------•------------------------•------•- Contractor's Name � -'� ��= Phone.. c ------------ -------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----I- Number of bedrooms _Number baths _l._._. Lot size ____---.____________-______________________________________ Water Supply: Publics stem y y ❑ r p pp y. y ❑ Communit system Frivate De th t ater Table __.___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous'Application Made: (If 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 204 feet.) Septic ank: Distance-from`nearest well___�0_/ DistancQ from foundation--- No. of compartments_______ --------- Size ---------Capacity....1c_a! _ Dispos Field: Distance from nearest well--- d------- / f s Distance from foundation to nearest lot line.______..___ ' Number of lines----------- Length of each line__ 9 d��--�---.�17Width of french---` __--------------------------- Type of filter material._- t _ Depth of filter material_____ F`__._Total length----- 'I'C ---------------------- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line____._______.- El Number of pits______________________Lining material-----------.------------size: Diameter----------------------Depfh--------------------------------- Cesspool: Distance from.nearest.well__,__.___.—_Distance from foundation--------------------Lining material-----_____.__..______________ ❑ t Size Diameter------------------------------ -------Depth----------------------------------- ------Liquid Capacity----------------------------gals. , Privy: I Distance from nearest well-------------------_______--------------------Distance from nearest building____.__________-____.___----_----_ ❑ Distance to nearest lot line__. Remodeling and/or repairing (describe)-................................. ...................................-------------------------- ------------------------------------ ----------------------•----------------------------------------------------------------•--------- 1 --------- ------------------------------------------------------------=---------- ------------------------•--------------•--------------------------------------------------------------------------------------------------- I hereby certify th a e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StaZ10s and regulat' of the San Joaquin Local Health District. (Signed)------------- ---- - --------- -- - ------ - -------- -------------------- - ---------------•-------- - ant!/or Contrac#or) By=--------- --- . .. ` - - ---------- (Title) --------------------------- - - - (Plot plan, showing size of lot, location of system in relatio o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT.USE ONLY APPLICATION ACCEPTED BY__'_Z ------0------------------------------------------------------ DATE--�F , REVIEWEDBY---------------------------------- ---------- -------------------------------------------------------------------------------- DATE-------------------•------------------------------------- - BUILDINGPERMIT ISSUED----------------------- ------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations------------------------- --------------------------------------------------------•--------------------------------------------------------------------------- --------------------------------------------------------------------------------------- ---------------------------------------- ----------------------- -----------------•------ ------------------- ----•--- ------------- ------------------------------------_--------------------- -------------------------------- ---------------------------- -------- ------------------------------ -------------------- ------------- ------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---- r ------------ Date----- - --------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 6-59 3M 3-'S3 F.P.CO.