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FOR OPFICE USE: ' - -------------------------------------------------------- I APPLICATION FOR SANITATION PERMIT Permit No. ..... 1. __/---�-� ----------------------- - --------------------------- (Complete in Duplicate) 9 l 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 wort herein described. This application is made in compliance with County J�_ Ordinance No. S�4+9.. L � JOB ADDRESS AND LOCATION_9J.i _.. �.�c.a.��1�� -------1�"�`�-�� --------------------- FOe Owner's Name-----U)-l. Y--- -- ---- - -------------- -------------------------- --------------- Phone------------------------------------- Address ----•-:•-----------•--•---------- �j� Address s'l - --------•-------_-�CJ� ' Y Contractor's Name Phone Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms Number f baths - Lot size ___ �' 1.�, .�,.______________________ Water Supply: Public system E] Community system El 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__"___" .._--- -I 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 Field: Distance from nearest well-----------------Distance from foundation___-___----___-__"Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench___-___,____________. Type of filter material--------------------------Depth of filter material------------------------Total length------------------------------------------ � r - Seep e Pit: Distance to nearest well--_,--k Distance from foundation-----�A....___.Distance to nearest lot lir e__- ___"____-_ Number of pits-------/------------Lining material-/d-4?.........Size: Diameter-----c;A1__------Depth__ __"___________"____"_ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material__---------__-____-________"_____-_ ❑ Size: Diameter------- ------------------------------.-Depth---------------------------------------------- Liquid Capacity-----------•----- ------gals. Privy:. Distance from neaiest well--------_:____"------------------------________Distance from nearest building-----."_____---_--_.----------__-___-"-_- ❑ Distance to nearest, lot lire-----------------------! Remodeling and/or repairing (describe):- -- ---------------------------------- -- -•---- •- -- r ---- -----------------••- ------ - --- -- ---- �� t ---------------------------------------------------------------------- -------------------------------k----------------------------- ---------------------------- --------------------------- ---------------------------------------------------- ---------------------------------•---------------------------------------------------------------------- ------- --- --- -- 1 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. 0 4 (Signed)----------- I _ -- ----- ------------------- ----- ---------- - --------------------- ----W------a--n--d--/--or Contractor) ""`r�" {Title)__ By:--------- �"C -------------------------------- ----------- -------------- - (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---- r -- - - � - ----- ---------------------------------------- DATE----- --- -3-1---,�r-------------- ------------- REVIEWEDBY------------------------------------------------------------------ ----------- ---------------------------------------------- DATE---"------ ----------•--------- -----------•-------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE"-------- - -------------------------- - - ------------------ Alterations and/or recommendations-- -------------------------------------- ----------------------------- -------------------------------------------------------------------------•------------- ---------------------------------------------------------------------------------------------- -----------------------------------------------------------------•---------------------------------------------------------- -------------------•---------------------- ----"------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------•-- ------- --------------------------------------------------- ------ -------------------------------- ----•----------------------------------------------------------------------------------- FINAL INSPECTION BY X, 1�. ----- Date__-- -----____-- -_- - �Z'lL. 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 E5 9 REVISED B-59 3M 3-'63 F.P.613. E