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FOR OFFICE USE: �F ------------------------------- ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _1 :�....... ----------------------------------------- --------------- = (Complete in Duplicate) _---_____.---._.._ This Permit Expires 1 Year From Date Issued pate Issued ___ �_,�,,t�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in complian e with Count q�d ace No. 549. 5�30 �� r e JOB ADDRESS AND OCATION--- ------ ------------------------------------------------------------------ Owner's Name------/ ..._..-- l... If -r------------ Phone Address -•---------------------------------------------------------•------------ ------...�d -ter '' - --------------••---- --- ---- Contractor's Name----- 11 ''1- --•------------------------•---- -------•------"--"--- Phone----------------•------------------ Installation will serve: Residence P� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: 1______ Number of bedrooms _3___ Number of baths -��"" Lot size _____V__ - Water Supply: Public system ❑ Community system 1H Private ❑ Depth to Water Table-r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam J8 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: I (No}septicgtank-or cesspool-permitted--.ifrpublic-sewer is-available-within-200-feefr) Septic Tank: Distance from nearest well___ 1�'_::Distancje fro foundation----- Ma erial____ ___________________.____-_.-_-____________- No. of Compartments_..._;L-------------------Size��-- �--�---Liquid depth--- !---------------Capacity--�°Z-�------ Disposal Field. Distance from nearest welL.i �3__ _.._Distance from foundation_/B__'-----------Distance to nearest lot line_r. w_______ -Q -Width of.trenck�-- -—' ----------- Number of lines-----_'_______________________Length of each line____ ; � Type of filter materiati , as._#"Depth of filter material__ __________-..-_._Total length___ea_�______________________________Seepage Pit: Distance to nearest w ____________ ____Distance from foundation--------------------Distance to nearest lot - line_______________ ❑ Number of pits"---------------------Lining material-------------r---------Size: Diameter-----------------------Depth-------------- �141Y ------------------ Cesspool; ----•---------Cesspool: Distance from nearest well_________________Distance from foundation___._-- L n ng material------------------------------------- ❑ �-Size: Diameter------ --------------------- -- ----Depth--------------------I -----------`-------- -=---Liquid Capacity----------------------------gals. t Privy: Distance from nearest well__"-_"__ ______________'--.-----.--; ------Distance from nearest building------____._________________------------- ❑ Distance to nearest lot line_____..:-.--._____*` " ' — I r 1 s Remodeling and/or repairing (describe):-------------------------------------------------------------------------- ------- ---------••--------- -------------------------------------------------------- ---- -------------•------------------------------------ ----------------------------------------------------------- "•--------------------------------------•-----•--------------------••-----------•--------------------------------------------------------- IY S .. I hereby certify that I haveprepared this application and that the work will be done in accordance with San-'Joaquin County c ordinances, State laws, and r les and regulations of the S n Joaquin Local Health District. g Signedlf- ----------------------------------------------•-------------------(Owner- and/or Contractor) -- - -- ----.�------- ----- {T.ttle) f (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---•-------- DATE--- _ ^ ' G REVIEWEDBY--------------------------------------------- ----------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED--------------------------------------------------------- - DATE Alterations and/or recommendations-------- ---------- ------ ----------------------------•---------------------------------------------------•---- -------------------------------- ------------------------------- . ------------------------------------- -------------+------------------------ --------------------- ---------- + I FINAL INSPECTION BY: -- Date_ j ------------ ------ -- ------------------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nozelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3"-63 F.P.CD. L-R