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FOR OFF{CE USE: - - APPLICATION FOR SANITATION PERMIT Permit No. _. .��r� -------------------- ---------------- ------------------- T_ --------------'--- ------------------------ ---- -------- (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 permit to construct and install the work her in described. This application is made in compliance Ith aunty Ordinance No. W. ADDRESSATION_.. � t .------ ,UR ` JOB - ------ , -- - ---- --------- on nn � Owner's Name- - ------ /Y�.----- s - ,'� Ph e. Addres ------ Contractor's ----Contractor's Name--------- ---------- -....... ------------- .I -- -- -•• ---------•--- Pho' ............................. Installation will serve. Residence ❑ Apartment House Commercial ❑ tTrailer Court ❑ Motel ❑ Other ❑ I Number of living units: -------- Number of bedrooms -------- Number of baths ---t--- Lot'size __-_------___-----' Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to'Water 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 200 feet.) Septic Tank: Distance from nearest well---------.-------Distance from foundation-_-----------------Material-----------------_----_-----_-------------------- ❑ No. of compartments--------------------------Size-------•---------------•--------Liquid depth-------------------------Capacity----------------------- Disposal geld: Distance from nearest we€I_`�---._Distance from foundation-----1.0-------Distance to nearest lot I le.-_- --___-_- fi Number of lines:__-----_:- -' - Length of each line------ ---- -_ir•--.Width of trench-----:rA------------------------ Type of filter material-__--__ - Depth of filter material--------1--._------Total length----- --------------- - Seepage Pit: Distance to nearest well----------------:--__-Distance from foundation....---------------.Distance to nearest.lot line--------------... ❑ Number of pits----------------------Lining 'material-----------------------Size. Diameter-----------------------Depth_.__-_-_----------_-.----- - -- Cesspool: Distance from nearest well-----------------Distance from foundation----------.........-Lining material---.7------------------------------ ❑ Size: Diameter--------------------------------------Depth y----------------------------------------------Liquid Capacity-----------------------gals. 'f Privy: Distance from nearest well----------------.---------------------7--......Distance.,from, nearest building----------- ------------------------------- t ❑ .5 P Distance to nearest lot lin --------------------------------------- --- -------------•------------------ --- - -------------- ---------------------I ------- • Remodelingand/or repairing (describe}----- -- ---- -- ------------------------------------------------------------------- ---------•--------------•------------------------------------•---• d' -------------•---------------•-------------------------•----•- -----------------11------------------=--------------------- ----- ----- '---------------------------------------- �-r --------------------- ----- -------------------------------------------------------•---------------------------------- ---- - ----------------------------------------------------- --------------------------- -- -------- I hereby certifythat I have prepared this - lica+ion_and that the work will be done in accordance with San Joaquin County ordinances, S+at and rules and regula dons 'the'San Joaquin�`Local Health District. - ------------------------------------------------------ and/or Contract (Signed) ---------- ---- - --- ----- a P ----- - ---- -------- -- - Title--------- o.-.. --------- 1 (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r ------ DATE---- "V^ ---.--- -------------------------- APPLICATION ACCEPTED BY- -------------- 4 REVIEWED BY----------------------------------------------------------------------------------- -------------•---------------------------- DATE------------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------- ------ DATE.------------------------------------------------------------- Alterationsand/or recommendations:------------------- ---------------------------------•----------------------------------------------------------------------------------•------------------- -------------I-----------------------•---------------. -------------•- -- -----------------------------------------------------------•---------------------------------------------------------------------------------- i •------------------------------------------------------------------------`-----------------------------------------------I-------------------------- ----------------------------- - ---------------------------- ------•----------------------------------------------------- -------------------------------------- ----------------------------------- ------------- t s j FINAL INSPECTION BY: � r�^�' 1 Date .�(v ` __- - -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 1 Stockton,California Lodi,California Manteca,California Tracy,California t E5 9 REVISED 5-59 3M 3-'63 F.P.CO. 11