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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.----------- o. ........................ (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. S/t e JOB ADDRESS 42 CATION _��__ r '�' -11 � 1� Phone = Owners Name-------- ----------------------------------------------•---------- • - -- --- - Address------... L J ry Contractor's Name----- •----------- t - ------------------- Phona. sz Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1---- Number of bedroom-Y___ Number baths _---___ Lot size :__-n�c�l"t-'-y ----•--------- Water Supply: Public system ❑ Community system-❑ Private Number to ater Table _f.'._:-_ 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 ❑; New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material________-____..___-__-_-___________------_____. ❑ No. of compartments--------------------------Size------------------`------------Liquid depth--------------------------Capacity---------------------- Disposal ield: Distance from nearest well_._._r�'_e" _"_.Distance from foundation-____1 ------Distance to nearest lot line__-___s______. Number of lines___.- �_.�_... _ ,------------Length of each line----- of trench____-.�J______----__________._ Type of filter matenal_.��.RL___r____-__Depth of filter material_-S4-_�--------Total length-----,�P_______________________________ Seepage Pit: Distance to nearest well--- ------------------Distance from foundatiort_________________.Distance to nearest lot line--_____.__.__---- LS1 ❑ Number of pits----------------------Lining material----------------- -.--Size: Diameter--------- ------Depth--------------- --------------- O 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 kne------------------ ------------------------ - -------------------- ----------------------------------------------------------------------- Remodeling and/or repairing (describe): --- - --;----------------•---•--•-----------•-------------------------------------- --------------•------- ----------••------------- ------------------------- t-------------------I——----------•----------------------------------------------------------------------------------------- .. -------------•-•----------------------------••--------------------•----------------------------------------------------A ----------------------------------------------------------- •------------- ------------------------------------•------------------------------------------------------------ ------------------------------------------------ I hereby er 'fy that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S ate aws, and rules an gulatioqinrela San Joaquin Local Health District. t - ------ ------------------------------------------------------------ - er and/or Contractor) (Signed)-------- B --- - -- -- -----------------------------(Title)------------------- ------------ ------------------------------ Y= (Plot plan, ing size of lot, location of systeion to w 1 buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ .____ _ _ . - - ---------------------------------------------------------- DATE- ------------------------------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------ ----- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE---------------------------------------------- ------------- Alterationsand/or recommendations:----------------------------------------------- ---------------•------------------------------------•-----•-------- --------•--•------------------------------ ---------------------------------------------------------------------------- --------------------------------------------------------------- -------------•------------------------------------------------_.------ - ---------- -----------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----•--------------- -------------- ---- -------------------------------- - ------- --------- -----------------------•-•----------- ---------------•------------ •------------------------------------------------------ w _"_ _' - --------•------ --------------- ---------------- FINAL INSPECTION ------------- BY:.. --- ---- - -- -- - --- --- Qate_ -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stacktonr California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CO. .I