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FOR OFFICE USE: y . : ----- ------ , APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) Date Issued ---- 3 _--- -----------------------------____-- -. 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. (0 L JOB ADDRESS AND LOCATION - 'S -••- - Owner's Name-------1-'_ G .l----------- ---------------------------------------------------- Phone__' `!'!r_- Address.. -------------- Contractor'sName__. s ----- --•- ------------------------------•- -- -- ----- - Installation will serve: Residence ET-"Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: Number of bedrooms J.-_ Number of baths ___I__ Lot size > --� _._ __ _---------------- Water Supply: Public system ❑ Community system El Private K Depth to Water Table 1 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 x FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 A14 Tank: Distance from nearest well-----------------Distance from foundation----_____________.Material____--_._____._---- ._.________---_-____.____. rc No. of compartments--------------------------Size-------••-----------------------Liquid depth------------------------- Capacity----------------- ----• 6, Disposal Field: Distance from nearest well.,57D........Distance from foundation___$ j__--__Distance to nearest lot line--S____-____- (�� Number of lines____,_______________ g r jj Len th of each line_--- ----------��•_----Width of trench------- --y_ ______;------- Type of filter material_—:5-e- �" -Depth of filter material___k_4___-----_-Total length------------------------ -------- Seepage Pit: Distance to nearest well-------------------__Distance from foundation--------------------Distance to nearest lot line---____.__.___-._ L] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._____________-----._____._____-. ❑ Size: Diameter---- ----------------------- ------Depth_._.. ------------------- ---------------------Liquid Capacity---------------------------gals. r Privy: Distance from nearest well ---.. -----------------------------------------_Distance from nearest building------------------------------- ----_____. ❑ Distance to nearest lot line------...-------------------------- ---------- ------- -------••------------ ------------------------- ------------------------ ----- Remodeling and/or repairing (describe):_ ..4 4------- --- —------ �. ------- ---------- ------- -------•--------------------------------------------------------------------------------------------- ----------- ---------------------------------------•-•-------------------------------------- ------------------------------------------------------------------------ --------------------- ---------------------------------------------------------------------------•----•----------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rules and regulations of the San Joaquin Local Health District. (5ignedl) Jt ;------------------------------ ------ w rier and/or Contractor)lB : -------------------------------------------•-- .x (Plot plan, showing size of lot, location of system in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY------- 1- _------------- - - - -- ------------------------------- DAT E------------ ---"�`------- ------- ------------------------ - REVIEWED -------- REVIEWEDBY----------------------------------- -------------- -------------------------------------------- ----------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------ ------------------------------------------------ DATE--------------------------------- Alterations and/or recommendations--------------- ------ ---------•-------------------•------------------•---••------------------------------------------------------------ ---------- ---------------------------------------------------------------------------------- --------•-- -----------•------------- .--------------------- - FINAL INSPECTION BY:.-- • �-.-/--�r' Date- --��e—; - 1- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Slocktonr California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'63 F.P.CD.