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FOR OFFICE USE: -------------I------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 19—.6 --------- ------- ------------------- ----- -------- (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 described. This application_is,made.in with County Ordinance No. 549. JOB ADDRESS AND LOCATION.. �'�� -----------------------------------•------------ Owner's Name------- 'A.- _�__�--------� - Phone------'----------------------------• Address--------------------�f/_....__� ------ --------------------------• ---------------------------------------------- ----ay-------a--- ---•---- Contractor's Name---/� -- ----------------------------•--._ ------------------ Phone-----------------------•---------- Installation will serve: Residence-EH Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..__ Number of bedrooms -------- Number of baths -------- Lot size ____-__--_____________________________-_-____------.----.- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table ........ ft. l 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 ❑ °v 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----------- -------- Disposal f=ield: Distance from nearest well--f0.-._----_Distance from foundation--_/b-.______-.Distance to nearest lot line-,r------------ Number of lines___1-----------------------------_ _ Length of each line------'?f----'-'-_ --Width of trench..._s�'_ _ �" Type of filter materia �$'�---._. _____ _Depth of filter material- f p _ 7Q - ------__ __-Total length----- Seepage Pit: Distance to nearest well-- -------------------Distance from foundation--------------------Distance to nearest lot line______-.___.___-- Q ❑ dumber of pifs----------------------Lining material-------.---------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- 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):--------- --------------------------•------------------------------------• --------------------•----------------------•------------------------------- --•--------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ -----•------------------------------------------------------- --------•------------------------------------------------------ - - - --------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. (Signed) ___________________ _ (Owner and/or Contractor) mg i� - ----- ---- --- ------- - - (Title) Y ---- (Plot plan, showing size of lot, oca*of i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - CAPPLICATIOND _ --------------- ------------------------------------------------ DATE_-_Y.:*17_0------------------ ----------------- REVIEWEDBY--------------------------------- ---------- ----- ----------------------------------- DATE------------------------------------------------------ ----- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DA•TE------------------------------------------------------------- Alterations and/or recommendations:------------- -- ----- --------•-------------------------------------•-----------------------------•------------------- ------ -------------- ------------------------------------------------------------------------------ ----------------------------------------------------------'------------- ---------------------------------------------------- ------------------ ---------------------------- ------------------------------------------------------------------------------- --- ----------------- ------------------------- - ----------------- ----------------------- - ------' - •------- --------------------- a,�_L 4� FINALINSPECTION BY: ------------------------ Date---- ---------------------- -------- -- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca, California Tracy,California F.P.CC. 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