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FOR OFFICE USE: -------------------------------------------------------- ______________________________-____--__.__.___.-_-.---- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (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 des ed This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATION_�'��±4r_- �- �� r Owner's Name `�.1r_ dIF ----------- Phone------------------------------------ -1-A --c_� Address 7 --------- -------1 Contractor's Name r' _T ------ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: ___t___ Number of bedrooms _ __ Number f baths _?-Lot size -----------------______________________________-____.------ Water Supply: Public system F] Community system [I Private Depth 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 ❑ 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 nk: Distance from nearest well___._P______Distance from foundation---IP'______.Material____CF. --_--.--- / No. of compartments----__-------------Size � _S�._J�_ ��_Liquid depth----(/_ ___------------Capacity__ ..Ad_. p sir Field: Distance from nearest well Distance--Distance from foundation---/D__r_____.Distance to nearest lot line_S_�_________ Dis o Number of lines--------/-------------------------Length of each line------ .A------------------Width of trench--_;?._ ------------------- --- Type of filter material__________ --Depth of filter material_____1_`L_...__,___.Total length---.-Laa _ ___--________________________ Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line_._____._________ ❑ Number of pits-----.I----------------Lining material-----------------------Size: Diameter--------- ------------Depth----------------------__--------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_..-_____________.______-_________ Size: Diameter--------------------------------------Dept h----------------------_ --- _ --. . Liquid Capacity Privy: Distance from nearest well________________r______________-.-______---____,_Distance from nearest building----------._-_----------_____--_.___-_.._. ❑ Distance to nearest lot line------------------ ------------------------------------------------------------------------------------------------------------- Remodeling 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, State law nd rules and regulations of the San Joaquin Local Health District. (Signed) . . •--• ---••--•----. and/or Contractor) ---------------- ------ ---- -------------------------------------- r By: - r '------ -----------------------------(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 i3Y__ __ ___ DATE___L '_' ___�r_ REVIEWEDBY--•------------------------------------------ -------------------------------------------------------------- - ----------------- DATE--------------------- -------------- -- --------------- BUILDINGPERMIT ISSUER-----------------------------------------------------------•---------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations---------------- -- --- --------------------------------------------------•--------------------•----•-------•--•-•-•---•------••-----------•------------------ -------------------------------•-----------------------------•----•-- ---------------------------------------------------------------------------------------------------••-------------------------------------•----------- --------------------------------------------------------------- -------- - - ----------- ----------------------------------------------------------•------------------------------------------------------------------------- ------------------------------------ ------------------- t ----------- ------------------ r FINAL INSPECTION BY: --------------------------- Date-- � 34 - ----------------------------- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:Ilton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.c;D.