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{ FOR OFFICE USE: T 1000 C = p ------------------- ------------------------------------- /� APPLICATION FOR SANITATION PERMIT Permit No. .... .......f..... ------------ ---------------------------------- --------- (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. ,p . . . -----•---- JOB ADDRESS AND LOCATION. r .. .----- •--. ------- ------ ------- -- --------------------------------------•-------- Owner's Name---------------G----------------- -----------�+ � ------��----------------------------------------------- Phone------------------------------------ Address............................... ...... a ......fes , - Contractor's Name---------------------• -• ----- ...•-•----------•---•--------•--.........---------•••....--............................................. Phone------------------------_- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms J___ Number of baths ________ Lot size ------------ .,f3�-/ ..................... Water Supply: Public system ❑ Community system K 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 ❑ No 11 TYPE OF INSTALLATION AND SPECIFICATIONS: /71 � (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Septic,T nk; Distance from nearest well.................Distance from foundation....................Material._-____.-__-__.-__._____,___________..___._--__•. No. of compartments-------------------------Size................................Liquid depth----- ------------------.-Capacity-_------------------- isposal Friel Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line. (� ❑ umber of lines-----------------------------------Length of each line------------------------------Width iof trench------------------------------------ ' Type of filter material_________________________Depth of filter material-----------------------Total length.......................................... �t1 Seepage Pit: Distance to nearest ell_ ._ _. ggistance f�o fo dation.................... s'stance jo nearest lot •ne Number of pits �mafierial_.�,�.; Size: Diameter. (v -ffJ__-Depth T�`:.. Cesspool: Distance from nearest well_________________Distance from foundation. -----Linin ,:Size: Diameter--- -------- __,,....__-----Depth=-------- _- ------------- ------Liquid. Capacity .,K ............gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_.___.._---_._-.-__.-.-_----_-_________._. ❑ Distance to nearest lot line----------------------------------------------------------------------- --------•-----------------------------------•-------------------- W Remodelingand/or repairing (describe):-----------------------------------------------------------------------------------------------------------------------•-------------------------------• `O ------------------------------------------------------------------------------------•-----------..........................................................------------------------------------------------------------------ ------------------•-----------------•------------•----•--••----------------------••-----•---•----•---------•-------••------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------- 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 ruI and regulations of San Joaquin Local Health District. ----------------------- --------- ------------------------------------------------------------- Owner and/or Contractor (Signed) ( / ) 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 APPLICATIONACCEPTED BY--------------------------------------- --------------------------------------------------------- DATE.... -•--./.. REVIEWEDBY--------------------------------------------------------------------------------------- ---- ----------- DATE_-- / --------------------------- BUILDING BUILDING PERMIT ISSUED------------------------------------------------------------------------ -------------- DATE---------------------- ------------------------------------- Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------------------------------------............... ....-....•-------------------- -------•--•-----•-----••----•----•-•-----•--•----••--••------- --------------------••--•-•------------------------------------------------•--------------------.------•------------------- -------------------------------------------- -•------------- ----------------------------------------------------------•------•--- ----------------•----•-----------•------•...---------------------------•--•---•---•-•-- -------------------------------------- ------------------------ ------------ -- ............ .......................... FINAL INSPECTION BY:. -------- -- Date. 1 . 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.CO.