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FOR OFFICE USE:. -------------------------------------------------------- ____________________________r____-____.------------ - APPLICATION FOR SANITATION PERMIT Permit No.1�_��.Y ------------------I--------_- ----------------- (Complete in Duplicate) Date Issued ------/ ��/o:_ This Permit Expires l Year From Date Issued Date Issued ------___7� f o 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 wi h County Ordinance No. 519. JOB ADDRESS A LOCATION-- .------------- -- - A------------------------•---••-------=-------- Owner's Name --- - ----------------------------•----------------------------------------- ------ Phone--------------- Address------------------ ,1� � Contractor's Name--------------------------��Ap`ament -----------•---------•------------ -------------------------------------------------------- Phone..-•-----------------------------•- Installation will serve: Residence House Commercial r] Trailer Court ❑ Motel ❑ Other ❑ Number of living units:._ Number of bedroo si----_- Number of baths __ Lot size ------------r__A_r----------------------_--_ Water Supply: Public system ❑ Community system ❑ .Private A Depth to Water Table _6--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: (if yes,date--------------------1 No New Construction: Yes ❑ No X. FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if+fiublic sew r/i �lable within 200 feet.) S Septio.Tan : r Distance from nearest weii! - --: ------Distance from foundation----1._ ------- Material----------------------------------------------- No. of compartments------------------1-----Size- -----------------.Liquid depth--------------- ------Capacity------ -- n i Disposal Fiel Distance from nearest well...7��/Pstance from found tion_-_-- _fJ----..Distance to nearest lo+ irk b *Y�F' _ -Length of each line _ f Number of lines__:__ X�Q_ '.7A.....Width of trench..-„ ______ r i, 7-------------- Type of filter material-15- Depth of filter materiae______________Total length----- __________._______-__ Akp4ge Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------.-------____.Depth_________________._.-_-------_- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.-_-_----__----__---_-__------- 1 Size: Diameter-------------- - Depth--------------- ------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------- m nea Distance frarest building---_----- ❑ Distance to nearest lot line-=------------------------------------------- - ------------------------------------------------------------- Remodeling an iring jdescribe}:_._.--_ ___G� __ _, G.�f_._ - ---_ p ------------- -- ----------------------•------------------------------------------------------------_---------------------------------------------_---------------------- - O - -- ------------------------------------------------------------- - - ------------ 1 hereby I have re ar'e�d application and that ---------=-------------- pc. � -- ---i--- •-• - - ---------•-- y y p p pp th work will be done n accordance with San Joaquin County ord' ante , State laws, and rules and u ions of the San Joaquin Local Health District. 7 (Si --------------------- ------------ --------a4ll =-------- --------------- (Owner and/or Contractor) ------------ ----------- =-----:.. (Title)_ ---•------------ -------- ----------•----------------- --- - ------------ lot plan, showi g size of.lot,rlocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY- -----•----- ---------- --------------------------------- ------- ------------ DATE- ------- ------------------------- REVIEWED BY- ----------- --------------- BUILDING PERMIT ISSUED------------------ --------------- DATE---_----------•------------------------ Alterations and/or recommendations: -------------------------------------- -----------•---• ------...------------•----------------------------------- ------- --------------- ------•-------- ------------------------------------------------------------------------------------------------------------------------------------------------------ I . --------------------------------------------------- r , ---------------------------------------------------•-----------------------.------------- -----------------------•---------------------- --------------------- ------------------------------- FINAL INSPECTION BY:............. --- 1 ^- - ---- ------ -- 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 Y. E5 9 REVISED 8-59 3M 3-'63 F.P.0 C. >y-