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FOR OFFICE USE: ---------------------------------------- ---------------- // // -------- -- ------------------------------- ----I-------- APPLICATION FOR SANITATION PERMIT Permit No. ..l_ � !_._? (Complete in Duplicate) S J r _____------------- This Permit Expires 1 Year From Date Issued Date Issued __...__I 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. ,f� 005— 25v_-2� JOB ADDRESS AND LO ATION_ ____ F Ph--- - r -- Owner's Name - ------- r-- ------ --- --------- ------------ Phone Address------------- )3/------------------ -------------------------------•------------.......------------------------------.. Contractor's Name-____k ----- --------- ------------------------------------------------------- Phone-------------------/-----•-------- ; Installation will serve: Residence E] Apartment House [-] Commercial E] Trailer Court E] Motel E] Other 2 "� Number of living units: __ .-_ Number of bedrooms _12— Number baths )------ Lot size ---- �-------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _______ ft Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑ 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: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) or ! Septic Tank : Distance from nearest well.... __---.--Distance from foundation------ Materia4__ __ _ ___.____-._-____ __ ____________- No. of compartments------2r_____-__--____Size_ __1�_�.-. '- _�_____Liquid depth----- !--------------Capacity__. d •�, Dispos Field: Distance from nearest well__04._.__-_Distance from foundation.....1_Q______-__.Distance to nearest lot line_��________-_-_ [ Number of lines- _-.__- `--- ----- ----Length of each line------?Q-i---__________.Width of trench-__.1`_-,-_______________-__ s e� r Type of filter material___________f-_____r_____Depth of filter material_____-f__8_.___-____Total length_-__-1_(y�_______________________._ Seepage Pit: Distance to nearest well___-------------------Distance from foundation----------.--------.Distance to nearest lot line----------------- B, ❑ Number of pits----------------------Lining material----------.------------Size: Diameter-----------------------Depth--------------------------------- L} Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_____.__----_________________________ 9 J ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------------------.._Distance from nearest building-_________-_____.-----___-----------___.-. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------- Remodelingand/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 1 an rules and regulations of the San Joaquin Local Health District. (Signed)-------- ----------------------- ----- ------- -- itaor.�nd/or, Contractor) F -- ---- ----(Title)--------- ---- (Plot plan, s ing 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 - ---------------- ------------------------------ ------ DATE---- REViEWEDBY------------------------- --------------- •- -------------------- ---------------------------------------------------•---.... DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------------..-. DATE------------------------------ -------- Alterations and/or recommendations:------------------ ------- --------------------------------------------------------------------•--------------- ------------------•------------•- ------------------------------=-------------------------------------------------------.--------------------------•----------------------------------------------------------------------- -----•------------------------ ---- -----------------------•-----------------------------------------------------------------------------------------------------------------• ------------------ -------------------------- ------------------------------------ --------------------------------------------------------------- - ------------------------------------------------------------------------------- -----•------------------------ ------•------------------------------------------------------- FINAL INSPECTION BY:--+df - Date ", -- 'S�-. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Kaielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS B REVISED 13-58 3M 3-'63 F.P.CO. J