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FOR OFFICE USE: ,C 0 I LI 4� rl.►'�'E" fix,.,,. APPLICATION FOR SANITATION PERMIT Permit No. ------------------- ---------- ---------------------- --------------•----- --------- ------ ---------------_-- (� � (� (Complete in Duplicate) Date Issued __________________________ t 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 AION......A�J&---••- ....... ------------------------........................................... r� ` ' a ----------- Owner's Name .. Phone - ---------------------- ----- fAddress j Contractor's Name------------_ ---•-........... ......... Phone Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑y Other ❑ Number of living units: ........ Number of bedrooms ---/--- Number of baths -------- Lot size ........ ---._•..................... Water Supply: Public system ❑ Community system /[I 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 F1 New Construction: Yes /K No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p 4 )�-t Se tic Tank: Distance from nearest well-/f ___._.Distance f foun tion__.a2 _______..Materia _ _ -�°- _____ ___ _________ No. of compartments-------- _--------___Size------( J _p___---Liquid depth._-�S--...____.Capacity./�__�__-_/_--__- \ Disposal Field: Distance from nearest welL%4T__Distance from foundation....i>7 Distance to nearest lot to ems--...__..... Number of lines ----- _ Length of each Iinef - :-- _ ..Width of trench-,:7.-X Type of filter material__1; __ epth of filter material.__ ---------_-Total length______.`1 _______________________ Seepage Pit: Distance to nearest well_.-----.--------------Distance from foundation....................Distance to nearest lot line................. (j ❑ Number of pits______________________Lining material-----------------------Size: Diameter-_.---.•__---.-_-_.----Depth---..._--._-__.-----_____________ Cesspool: Distance from nearest well_________________Distance from foundation---------.----------Lining material--_.-_---_--__--.______----____--_-_. ❑ Size: Diameter------_----------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------.-------------------- ____________________Distance from nearest building---.-----------------------------------... ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------•--------------------- 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 rules and regular' f oth San Joaquin Local Health District. (Sigr�pd)-------------------wz--- ------- ------ ------------------------------ --------------------------------------------------------------- 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 APPLICATIONACCEPTED BY---------------------- --------------------------------------------------------------------------- DATE---------------------------------------------------------- REVIEWEDBY----- _------------------------------------------------------- ------------------------------------- DATE------ -------------•--------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------- ------ DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------------------------- -------------•----------------------------------------------------------.-----------. ......................... ------------------------------------ -----------------------------------------------------------------------------•-------------------------------------------•------.------------------------------------•------------------- ---------------------------------•-------------------•------•- -------------------- ---------------------------------_..._..------------------------------------------------------------------------------------------------ -----------•----- -------- ----------------------------------------------------------------------------------------------------- ----------------------------------------------------------- --------------------------------- --------------------------------------------------------------- -•---- - --- --- FINAL INSPECTION BY-------------- ---------- ------ C � Date. - .... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9fh Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.CD.