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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------- -------- ------- ---- (Complete in Duplicate) -.--- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desc?bgd. This application is made in compliance with County Ordinance No. 549. r( 7,Lr.,j� JOB ADDRESS AND CATI - --- --- t ------------=------- Owner's Name---------- --Q -- -----•------- ---------------- -------------------------------------------------- ------- Phone-------------------- --------------- Address........... �------ ----r4�- Contractor's Name------ ------ ------- ,�.r�- -- ------ -- ----- - ---- Phone-------------------"--- -- Installation will serve: Residence e Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms __`___ Number f baths __ ___ _ ate.._ _ Lot size .----- -ae- ••----------------------- Water Supply: Public system ❑ Community system ❑ PrivateDepth o 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....................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 del?Ah---------------- ---------Capacity----------------—---- Dispos Field: Distance from nearest well... .._Distance from foundation /V___"__._.Distance to nearest lot line---------------- r -------lines------------- line------ of trench.____._"_,f______________________ to Type of filter materia[_.__ _._.--Depth of filter material_____��___-_""_Total length-_--_-641-------------__"__------_- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--_--_--_-.__---- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter.----------------------Depth--------------------------------- .� . C Cesspool: Distance from nearest well_________________Distance-from foundation-.______________..Lining material-------------------------------------- Ip ❑ Size: Diameter Depth ----------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----_-----_-_--_----_-_--__--__-_-._-----. ❑ Distance to nearest lot line------------------------- -------------------------------------------------------------------------------------------------------------------- F Remodeling and/or repairing (describe)=------------- - `-----------------------------------------------------------I•----------------------------•------------------------ --------------------------------------------------------------------------- -• - --------------------------------------------------------------------------------------•--------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- -- ----------------------------------- -• ----------------------------------------------------------------------------------------------, --••---------------------------------------------------------------------------- I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County ordinances, State I n rules and regui Ions the San Joaquin Local Health District. (Signed) _ ~{ and/or Con+rector} ----------------------------------Title (Plot plan, showing size of lot, location of system i relation to w Is, buildings, etc., can be placed on reverse side). �r FOR DEPARTMENT USE ONLY w APPLICATION ACCEPTED BY --------------- --------------------------------------- DATE �f ------------------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE----- ----------- ---------- -- ---------------------------- BUILDlNGPERMIT ISSUED--------------- -------------------------------—----------------------•-----------• -- DATE--------•------------------------ - Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------- ------------------------------- --------------------------. -------•----------------------------------- -- -------------------------- -------------------------- ----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------.. --------------------------- --------------------------------------------------------------------------- ---------- -•--------------------•-•--------- ------------------- ------------------------------------------ --------------- Dated FINAL INSPECTION BY: . ...... ..... . . ---------------------------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street S196fan,California Lodi,California Manteca,California Tracy,California CS 9 REVISED 0-59 3M 3-'63 F.P.CC. 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