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FOR OFFICE USE: A- ------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...... ...:3>.... ----------------- --------------------------------------- ------------ ----------------------------- -------------- .... (Complete in Duplicate) Date Issued -------/--- --------------------- -------- -------------- This Permit Expires I 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 AN LOCA WN......I---- -- ---- ---- ........ --------------------- --------------------------------------------------- Phone............................. Owner's Name-------- --- --= ....... ...... ---------------?T �................................ Address ------------------------ Contractor's Name...-----_-_------------- ......... ---- —--- ...............................--------........................................................................ .. . Phory ..... . Installation will serve: Apartment House Commercial Trailer Court E] Motel 0 Other C] k E] _37 Number of living units: Number of bedrooms --------fE]Number of baths _---..1. Lot size ------------�._25-I;' .(........................ Water Supply: Public system 171 Community system Private E] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand [-] Gravel E] Sandy Loam E] Clay Loam ❑ Clay Adobe 0 Hardpan F] C Previous Application Made: (If yes,date--------------------) No New Construction: Yes ❑ No FHA/VA: Yes E] No J TYPE OF INSTALLATION AND SPECIFICATIONS: (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TonL,4--,1 I istance from nearest well-----------------Distance from foundation--------------------Material----------------------------------- No. of compartments--------------------------Size_____________________ Liquid depth-------------------------Capacity---------------------------- Disl5osal Field: Distance from nearest well -C.-Distance from founclation...,ZZ--z-_--Distance to nearest lot line...../.�2.... ❑ "-_�er of lines -- ----- -----------�ength of each line..Y- _4� 7,;�k'Width of trench......A211 -------------------- u -----------A Type of filter material--- epth of filter material_-_ -------- Total length.._......,`;__ `--------------- Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line--_.---.-_.--_-._ F1 Number of pits--------------_-----.Lining material--------_-------------Size: Diameter.---_--_--------.-.._.Depth--------------------------------- Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material----...-..-.-..---_..._.._-.--__-_--.. ❑ aterial-------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-.------------------- ......gals. Privy: Distance from nearest well------------------_-----------------------------Distance from nearest building-------=----------------- r_1 Distance to nearest lot line----------------------------- ----------------------------------------------------------------------------------------------- --------------- Remodelingand/or repairing (describe):----------------------------------------------------------------........................................................................................ --------------------------------------------------------------------------------------------------------------------------------------------------------1�------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ------- -----------------------------------------------------------------------------------------------------------...............------------------------------------------------------------- _---------------------- I herebc er fify that I hAve p epar cd t is application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws, and ales nd r ul #ions of the San Joaquin Local Health District. - -----------------------------------------------------------------------------------------------------(Owner and/or Contractor) (Signed)---------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 APPLICATIONACCEPTED BY------------- ------------------__---------------------------------------------------------- ---------------------------------------------------------- REVIEWEDBY---------------------------------------------- ------------------------------------------------------ DATE------------------------------......----------_---------- BUILDING PERMIT ISSUED--------------------------------------------------------------................. ATE------------------------------------------------------------- ---------- Alterationsand/or recommendations:------------------------------------------------------------------ .................................................................... ------------------------------------------------------------------------------------------------------ --------- -/� ----- ---------- ------------------------------------------.................................------- -------------------------------------------------------------I-------- -------------------------------- -----------------Z......--------------------------------------------------------------------------------- -------------------------------------------------------------------------------------I------------------------------ --------- -------------------------------------------------------------------------------------- ------------------------------------------------------------- -------------------------------------------------------------------------------------------------I---------------------------------- ------ --- ------------------------------ ------------------ -------------------- Date 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 99 9 REVISED 8-59 3M 3`63 F.P.120.