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FOR OFFICE USE: - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. __1-.73._ --------------------------------------------------------- (Complete in Duplicate) �-5 Z ----------------------------------------------------...___ This Permit Expires 1 Year From Date Issued Da Issued Application is hereby made to the San Joaquin Local Health District for a permit to constr an Install the ork herein desc,bed This application is made in compliance with County Ordinance No.•549. 10 c� JOB ADDRESS AND CATION- -- -- > � Owner's Name__-__ rx - -------------- Owner's ----- Phone------------------------------------ Address - - ---------- -- ------ ------ -- ------------ - ------------ Contractor's Name------------ _ j Insfallatiion will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ _ Number of bedrooms - Number f baths _,/___ Lot size _-.-___ _____-____ Water Supply: Public system El Community system El Private Depth to Water Table ______ ft. Character of soil to a depth of 3 feet: Sand F] Gravel F] Sandy Loam E] Clay Loam E] Clay dobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________I 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 Tank: Distance from nearest well-----------------Distance from foundation--------------------Material-_------------------_______________________.__. ❑ No. of compartments-- ------------------- -Size--------------------------------Liquid depth-------------- -----------Capacity--------------------- Dispos Fieid: Distance from nearest well---5-0e? -Distance from foundation-----1_----------Distance to nearest lot line_.,S______---- Number of lines---------- ________ __ Length of each line____ _f______.__.Width of trench-.--_� p____________________ Type of filter material--- _-Depth of filter material----.---/_�1�---Total length___.__ Ip-i_____-__._._.______ H l f Seepa #it: Distance to nearest well____1_� ........Distance fr undation-----L_p_______.Dist ice to nearest lot line__x .__...� I 0 Number of pits___________ __________Lining material___. __ __ _.-__.Size: Diameter_____��3____-.___Depth__��_____________.__--._ Cesspool: Distance from nearest well_________________Distance from foundation--__.------------- Lining material------------------------------------- n Size: Diameter- ---------------------------- -------Depth-------------------------------------------------_Liquicl Capacity----------------------------galI— El A Privy: Distance from nearest well_______________________________...__________'-Distance from nearest building----------------------------------------- Distanceto nearest lot line-----------------------------------------------------•------------------------------------------------------------------•------------------ Remodeling and/or repairing (describe):_ --------------------•------ =------------•-------------------•-•-------------------------------------------------------- "---' ----- ----- ------------------------------- ----------------------------------------------------------------••---------_---..----•-------------------------------•--------------•-------..._..-------------- -------------------------- ---- -------. --- ----------------------------------- -- --•-n--•----------•••---------------------••---------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and regulations of the San Joaquin Local Health District. (Signed}--------- --- • --------------- -- -- - + ---------- nd/or Contractors � .cEly:-------- ----------------- --- -- --- -- - (Title) (Plot plan, showing size of lot, location of system in elation to weIQ buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-,,1�Z, --------------- ------- DATE__c� _('/±-------------------------- -------------------------------- ----- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE ----------------------------- BUILDING PERMIT ISSUED-------------------------------- --------------------------------------------------------------------- DATE----- ----------------------------------------------- Aiterations and/or recommendations:------------------------- ----------------- --------•---•• -------------------------------------------------.--------------.--------------- ------------------ ---------------------------------------------•-------•---------------------------------------------------------------•-••----------------------------•----------------------------------------------•----------------------- ------ ----------------------------------------------------------- ------ - - ---------I------------------------------------------- r f FINAL. INSPECTION BY:- ----- -------------- Date- ~V!k -------_------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Are. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED H-59 3M 3-•63 F•P.CO. 1 J