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FOR OFFICE USE: a- Da � � ~I z I ----------------------------- -------------I------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------- ------------------------------- -------- (Complete in Duplicate) / Date issued --------------------------------- ----------------------- I 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. G JOB ADDRESS AND CATION __________- _ ;_ Owner's Name______________ - -vG Phone -------_-------------7 Address. . ----------------------------------------------•---------- --------------------- :- = 1� .... 1= Contractor's Name ' 2pa�rtment ti ---------------------------------•--. Phone................................... will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel / Other E]Number of living units: ._'____ Number of bedrooms -AZ' - .1...._. Number of baths . __._ Lot size ___- ___.__ __.T__.t�_ _ _ 1_______________________ Water Supply: Public system ❑ Community system D� 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-----------_--------) N*- New Construction. Y s 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 19-n],_ Distance from nearest well_________________Distance from foundation----------------.__.Material------------------.----------------------______-- No. of compartments---------------- ---- q i? ------- Capacity--------------------•-- /e,, Size_________________ . Liquid th___.._________. . _ Disposal Fi : Distance from nearest well__jo Distance from foundation.. --/_ -------Distance to nearest line.8;1........... Q Number of lines_-___1'--------r____________ __Length of each line....:3.a`_'�t___ __-tf-------Width of trench._____�`� C/ �1� a �✓( Type of filter material. __��=� Depth of filter material__ ___________Total length.............. _ -__________________ /'- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__--_-___ ---_---- f ❑ Number of pits______________________Lining material----------------------.Size: Diameter__ --------------------Depth-------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------------- 0 Size: Diameter--------------------------------------Depth--•------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well---------------------------------___------------..Distance from nearest building--------___-____________________________- ❑ Distance to nearest lot line------------- --------------------------------------------------------------------------------------•----------------------•---------------- Remod ling an /or r air',g (describe):___ 1. 1� _, y_ 1_ �F-e .�_ __._:% l -- = k �- --------------------------------------- ----------------------- --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ LA 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 rules and regulations of the San Joaquin Local Health District. I s (Signed)----------------------------------------------------------------------------- --------------- -------------------------------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------(ritle)---------------------------------------- ------------- ---- (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---------------------------------------------------------- REVIEWED BY-------------------------------------------------------- �� DATE... _ -.� <- ; BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------. 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 95 9 REVISED 5-59 3M 3-'63 F.P.CD.