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IvRvrrlt,c uDc: L ' ' + --------------------------------------------------------- -------- ------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ___-/.-_/ Z -: Q ------------------------------ -------- ---------------- (Complete to Duplicate) • sued - -------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Is ,-. 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. S49. JOB ADDRESS AND OCA710N � ` Owners Name------ -- ---------------------- Phone------------------ --------- Address----------------A. .._..� _ _.__ - e -•- -•- �F� ------------------------------------------------- Contractor's Name--- ---------•--•------------------•-----------�^--•--- ----------------------------------------- Phone----------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __!__ Number of bedrooms _3___ Number of baths le----- Lot size -_-___-3_f____________________________ Water Supply: Public system E] Community system [-I Private �0 Depth to Water Table 7D_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam M Clay [) Adobe❑ Hardpan.8 t Previous Application Made: (if yes,date--------------------I No New Construction: Yes-4 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___.S-o___-Dist nce.from foun tion__.1_!%_______-__.Mdt rial___ ------ -____-----. �] No. of compartments_____�r_ -__Size_-------____ __fid _Liquid depth______7_______________Capacity/A,---___:___ Disposal Field: Distance from nearest well--- Distance from foundation_____-40-------- to nearest lot --------- Number of lines________ _____ Length of each line___�d'"_P_____`____-__-Width of trench—XV-0______-.__._________ Type of filter materia ______� ....Depth of filter material___ _________Total length------.`__V_V--____________________ Seepage Pit: Distance to nearest well____/_0_P7V--------Distance from f undation---J.Q.........Distance to nearest lot J line___ ----------Number of pits-_-._ -_- Lining mafieria . -----Size: Diameter-- Depth.___._ ____r______�____-_._-___ Cesspool: U Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------.__-_____________._______. g ❑ Size: Diameter------ -------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----________-_______________--__-.____.-. ❑ Distance to nearest lot line ---------------•=----------•----------------•-••------------------------ - --------------------------------------------- Remodeling ------------------ ------------------------Remodeling and/or repairing (describe):--------- ------------------------------------------•-----•----------------------------------------------------------------------------------------- ---------------------•---•-•--•---------------------------------------------------------------------------------------------------------------------------------------- -------------------- -------------- ------------------------------------------------•--•---------•-------------•-------------------•---------------------------------------------------•------------------------------------------------------------------------ ----------------------------------------------------------------••------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------------------------------------------- --- ------------------ (Owner and/or Contractor) By� ----------------------------------------------------------------(Title)---------------------------------- ----- --- (Plot pian, showing size lot, location of system in relation to wells,-buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY_ •. ------------------------------------------------- DATE----- �------------------------ - REVIEWEDBY------------------------------------------------------------------ ----------------------------------------------------------. DATE------------•----------------------------------------- ------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------- ----------- Alterations and/or recommendations---------- ------------------------------------------------------------------------------------•-------------------------------•----•-------------------------- ----------I-----------------------------------------------•---------------------------------------------------------------------------------------- ---------------------------------- -------------------------------------- -----•---------- -•-----------------------------------------•------------------------------------------------------------------------------------------------------- -------------------. .------------ ------------------ ------------- ------------------------------------------------------------- -------------------------------------•--.-------------------.---------•------•-------•-------------------------------- --•----------------------- FINAL INSPECTION BY:.� �- .- �.3 /'�---- !f' --------------------- Date f ------------------------------------- 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 ES 9 REVISED 6-59 3M 3-'S3 F.P.CD. _ 5 ,