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FOR OFFICE USE: 14009 k �°� . y 2►D APPLICATION FOR SANITATION PERMITPermit No. .�.....�� --------------------------------------------------------- ......! _.... --------------------------------------------------------- (Complete in Duplicate) Date Issued _�.__�3p_�r5✓ ---------------------------------------------------------- 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. p . . . JOB ADDRESS AND LOCATION ... .. . ......... .. " �`� '�l ------ -- ----------------------------------- Owner's Name................................... ----------- ------------------------------------------------ Phone-----------------------------.------ .Address-----------------•-------G`---- --------------;.... ------------------------------. --------•---•--------------------••-------... Contractor's Name--------------------;. --- - ...---•----------------------------------------------------- --------------•----------------------- Phone................. Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms J... Number of baths -------- Lot size ---------'j-0-1d_l _____________________ 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 ❑ ClayX Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ N0119 TYPE OF INSTALLATION AND SPECIFICATIONS: st (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SeptiAl clT nk> Distance from nearest well-----------------Distance from foundation....................Material_______-_________--_-___-__---------.-.-____---•. I No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- isposal Fipld: - Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line.. (� ❑ -Number of lines-----------------------------------Length of each line________-.-_____--___________.Width of trench------------- _____-__-______-__ �3 Type of filter material-------------------------Depth of filter material-----------------------Total length________________-:----_____-_---____--____ �A Seepage Pit: Distance to nearest elll,� �istance f fo dation.................... 'stance-to nearest lot nerf.�._.___._ �j Number of pits--- - mafierial__��—Size: Diameter_/�/r.:�,>___Depth - D Pi Cesspool: Distance from nearest well_________________Distance from foundation.-- ---- -----------Lining -_ _ ----- ------------- __ ____. ❑ Size: Diameter-------------- ; --------Depth----- ------Liquid. Capacity .--•-•---...-------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---.-________________________--__________- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------•----------------•------------------- W 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 laws, and rule and regulations of San Joaquin Local Health District. --------- Owner and/or Contractor (Signed)------------------------ 1�° ---------------- --------------------------------------- ( / 1 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-------------------------------------------- -- ----------- DATE..... . / -------------------------- BUILDING PERMIT ISSUED....................--------------------------------------------------- ---------- AV-1.._ DATE---------------------- ------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------- -------------------------------------------------------------------------- -------------•------------------------------------------------------------------------------------------------ - ------------------------ ------------------------------------------------------------------------------... ----------------------------------------------------•-•--- --------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- ------------ ----------------------- FINAL INSPECTION BY:. 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 ES 9 REVISED S-59 3M 3•'63 F.P.CD.