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FOROFFICE USE: = ----------------------------- ------- �- --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ------ ------------------------------- (Complete in Duplicate) Date Issued Cr/ /`-�j This Permit Expires Z Year From Date Issued r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here' ribed. • This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION/ ------,. ------_ -------------- ------- ---------------- ! __ Owner's Name------ ---7 --- - ---- - -- ---- ------ ------ ------------------- ----- ------------ ------. Phone------------------------------------ 1s Address-._.- � - --- -•-------••------------ - --------------•------ -----------•--------------------•------------------------- Contractor's Name--- --- s ------------------------------------------------------------ Phone----- ----. ---------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court(DMotel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms __07-'Number of baths J____ Lot size -e-e____ _______.___ _______________.__--_ Water Supply: Public system ❑ Community system ❑ Private 6 Depth to Water Table Z-Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam LTJ Clay ❑ Adobe❑ Hardpan Previous Application Made: (if yes,date---------------------) No Ve' New Construction. Yes ZNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well---�p-------Dista �e`from found _ation___ a--_--____.Ma#epal_______________________.._________----.._______- No. of compartments____._' __________ __Size_ 2°.rf1� !P-Liquid depth----- _7 -r ___Ca Dispos Field: Distance from nearest wefI- %$_____.._Distance from foundation----f_Q____......Distance to nearest lot line_S_._______- Number of lines---------- ...---_._____ _ Length of each line_--_---To----AO------.._.Width of trench______________ Type of frlter material-__-. Depth of filter material___.._,f _______._.Total length-._.__�(__4_ _-._ Seepage Pit: Distance to nearest well------ ---------------Distance from foundation---.----------------Distance to nearest lot line----------------- 171 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- -- from nearest building__________.---_____________------------._. ❑ Distance to nearest lot line.----- -- RemodRemodeling eling and/or repairing (describe):-------------------------------=----------------------•- •----------------••---------------•---------------------------------------------- •------- ----------------------------------•------------•-•------------•---------------------.---- ---------------------------------•--------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules nd regulations of the San J aquin Local Health District. (Signed) -- - w -----------------------------------------------(Owner and/or Contractor) By:-------- -----• ----- (Tttle)-------------------------------- - ------------ -I (Plot plan, showing size of lot, location of system in re tW ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------------------------------------------------------- DATE-- ' REVIEWEDBY--------------------------------------------- -------------------- ------------------ ----------- ----------------------- --- DATE----------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:----------------- ---- ------------------- - -----•--•----------------------------------------•---•------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ FINAL INSPECTION BY:.. �'� �r��•,..�,._-------------- ------- 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 Es 9 REVISED B-59 31A 3-'63 F.P.CC.