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FOR OFFICE USE: ------- ---------- ---------- --- ----------------------- APPLICATION FOR SANITATION PERMIT Permit No. __..__.._____..____..___ --------I------------------- - - .------ ----- (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 compliant with County Ordinance No. 549. JOB ADDRESS AN CATION-..___-`�`"---- __ _------------ ___e�?y_ Owner's Nam. ------- --•- -----------------------• ---------------- Phone------------••-•----------------- - 2 ---------------------------- Address------------------ 3 -- Contractor's Name-------- --------------------- ----- ------------------------ Phone---------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._.__ Number of bedrooms __/__ Number of baths(---___- Lot si&PY_ --- __________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel [-] Sandy Loam F] Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ 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 ank: Distance from nearest well__so�____.Distance from found tion___/0-------Mate iaL_ No. of compartments----C;2L-_ ---- -----Size. ` -Y-� Lf iquid depth-------�.-----------Capacity_S&.Q-A_-- r � Dispos tFielcl: Distance from nearest well--�'�---__Distance from foundation..-_/P___s_----.Distance to nearest lot line.&---__-__ . Number of lines______------ Length of each line------- __r___.Width of trench------- ?Z_,T____________-_______ i Type of filter material_-_-_____ __________Depth of filter material________ --------Total length--------f .__._.--____-.----_--__ Seepage Pit: Distance to nearest well---------------------- from foundation------------------- Distance to nearest lot line----- _. --. �f ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----4_-'------`:------Depth------------------------------ -• •�� Cesspool: Distance from nearest we#I_________________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----------------------:-------------------------------------------------------------------------------------------------------— - Remodeling and/or repairing (describe)--------------------------------------------j-----------•-----------------------------------------------•-----..---------------------•------------------- Apr --------------------------------------------------------------•---------•------------------------------------------------------------------------------------------•- ----------------------------------------------- -•-----------•-------------------------------------------------------------------------------------------------- -------------- ----------------------------- -----------------------------•-•--------------------------------------•------------------------------------------------------------------------------------------------------------------ I hereby certify-++ t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, d rules and regulations a San Joaquin Local Health Distric+. (Signed) --- • ---•-------• -------- - ------ - ------------------- ---- - --- ---- ---------- w T�td or Contractor By: = t ------- -- (etre} (Plot plan, showing size of lot, location of system in rela ion to wells uildings, etc., can be.placed on reverse side). FOR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------- DATE 1_'LY-� REVIEWEDBY-------------------------------------------------------- ------------------------------------------------------------------- DATE-------- ---------------------- BUILDINGPERMIT ISSUED--•-----------------------------------------------------------—-------------------------------------- DATE-------------- ---------------------------------------------- Aiterations and/or recommendations:---------------------------------------- -----------------------------------------------•-------------• ---------------•-------------------.._...---- -------•-•-----------------------------------------------•-----•--------------------------------------------------------=-------------------------------------------------------------------------------------------------- -------------------------------------------------------• ---------------------- ------------- ---------•----------------------------------------------------------------------------------------- ---------- ----- -- -------------------------------•------------------- FINAL INSPECTION ----------- - ---------- 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 REVISCO S'S9 3M 3-'63 F,RCO.