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FOR OFFICE USE: I G OO 3 T RA,l p4vl' ___________________________________._-____________- APPLICATION FOR SANITATION PERMIT Permit No. ............ -------------------------------------------------- (Complete in Duplicate) 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 work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATIO �y �� -------Z --�- � Y-------------------------------------------------•--•----- Owner's N e.......... --- -• E - -- --- ---- --------------------------------------------- Phone...... � Address � f �7.1�`--- - ------------------------------•--------------------•------------ Contractor's Name --------------------------------------------------------------------------------------- ----- Phone................................... will serve: Residence •x Apartment House ❑ Commercial ❑ Trailer ourt ❑ Motel ❑ Other ❑ Number of living units: _ ..__ Number of bedrooms I_-- Number of baths ---(-_- Lot size ...x_ z)... •__-_--•_______________ Water Supply: Public system ❑ Community system ❑ 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__.------- ---------) No New Construction: Y -NoFHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic tan istance from nearest well_________________Distance from foundation--------------------Material---------------.__-___-_________-__-_-______-_-•. No. of compartments--------•-------- -----S�i�ze--------------------------------Liquid depth Capacity-•-•------ Di o al Field: Distance from nearest we I-/�� istance from foundation_.__ __1_....._.Q�isb rice to nearest lot tIi ----------- a _.._._.__. Number of lines._.___, per,______ Length of each linell�__.e�b.r _ :749th of trench c _ rA` Type of filter material �2 Depth of filter material Total length ............----------------- "�1 Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits______________________Lining material--------------.--------Size: Diameter-----------------------Depth_____---______-___.______-__-_- Cesspool: Distance from nearest well----------_------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_---------------------_---gals. P I - _ Privy: Distance from nearest well ________ _ -_ __ _____ _____________Distance from nearest building-------------------------------------- ____ _____.__ _..___-_________-_. ❑ Distance to nearest lot line ---- --------- -------------- ------------------------------------------------ Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------- ------------------------- I hereby certif that I have prepared t 's application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and re atl ns of he an Joaquin Local Health District. (Signed)-------•-- ----•------------ ••----- --------- ---------- -------------------------------------------••---------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)----------------------------------- -------------------------- (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-------------------------- --- ---------- REVIEWED BY ------------ ATE ------------------ --- BUILDING PERMIT ISSUED---------------------------------------------------------------------------_....... ATE------ ----- ------------ -- - - ' Alterations and/or recommendations----------- ----------------- -------------------------------------- ----------------------------------- ----------------------------------------------------------------------------- ----------------------- ----------------------------------------------------------------------------------------------••------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- .-.-------------------------------------------------------------- ------------------ -----------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------------------•- - -------- Com-- FINAL INSPECTION BY: ---'---�--- Date---- _n)--9--------6...... --------- -------- 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 9-59 3M 3-'63 F.P.CD.