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FOR OFFICE USE: 12DQa t� ----------------------------------------------------- APPLICATI9N FOR SANITATION PERMIT Per*, No. ... , .•>`.••- ----- ------------•---------- ------------------------ (Complete in Duplicate) T ��LI �- This Permit Expires 1 Year From Date Issue ssued -____ 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 'th County Ordinance No. 549. \ r JOB ADDRESS AND L C TION__ „__ -__ _- t -- -- ------------------ --•-•- Owner's Name------ - ---- -- -------- -••-•-----------------------------------------------------•-- Phone--------------------------------- Address...4 3---.------------- ..... Contractor's Name------ .. _...--- -- - - --------------------------------------.................. Phone---------................ Installation will serve: esidence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms -------- Number of baths O-___ Lot size Water Supply: Public system ❑ Community system ❑ Private ixDepth 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 X, New Construction: Yes ° No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s7wer is available within 200 feet.) ( Septic Tank: Distance from nearest well----4 0-.._Dista fr9m foun�ion-----.,�_Q__----'Mat er- I______f`O...______... ................ No. of compartments..____, _._'_------------5ize..�XPX_5_.__•Liquid depth__-.-�� _.---Capacity----��Q_____- Disposal Field: Distance from nearest well10. Distance from foundation_____i_-------Distance to nearest lot line.�2r'�____---- Number of lines-------- ^^- Length of each line____.,j"4_______E_,___,.Width of trench----2-4--------------------- Type __________________ Type of filter material.�--L___�_Depth of filter materia l___-xd------------Total length_.._.. ................. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line-..... .._-.____ ❑ 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______________.__________________ Remodeling and/or repairing (describe):----- "_ r '1,,-------k!K�---7 -&--C-e.�¢Q.� -----------------•-------------------------------------------.----------------------------------•--------•-------------------------------------------------------------- ------------ --------------.--------•-------- ------------•---•----------------- --------------------------------•----- ...........--------------------------------------------------------------------------------------------------------- ------------------------ 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 regulations of the San Joaquin Local Health District. (Sighed le&--------------------------------------------------------------------------------(Owner and/or Contractor) •-•---------- ------------------------------------------------------ -------------• - 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 APPLICATION ACCEPTED BY------------------------------------------ ----- -----------•-... DATE REVIEWEDBY--------------------------------------------- ------ -- . DATEf -------- BUILDING PERMIT ISSUED ----•- DATE---- - -----fir Alterations and/or recommendations: -------- ---------------•---------------------------------------------------------------------------------------------•-----------------•--------•----•-------•--..._....----------------.•------------------------_--------- ---•-------•--•------------------••---•-----------•---------------------------•---•------------------------- •--------------•---------•--------....------------------•-------•--•-•----- -•---------•-------------....... 16i; FINAL INSPECTION BY: A.............a2-•----------- ------------------- Date /__. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amstrican Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS X