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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---- -- ------ --------- -------- -------------------------------- -- --- ------- (Complete in Duplicate) 1. ----------- -------_ 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 compliance with County Ordinance N.P. 549. ---- 4*0---2-7 I JOB ADDRESS A L C ION-- a-L4A, _._`` .., 3-` �` _ ----- �-------- Phone----------------- ------------------ Owner's Name--------- -- ------ --------- ----- •---- --- ••- --- - -•-•----- - ------------ ' ►+ l - ----------- Address..-•----•-•------ ------- -- ---------- --------- ---- --------------- - Contractor's Name------------------------------ -- ----- ----------------------- ---------------------- ---------------------------- Phone................ Installation will serve: Residence ❑ Apartmen 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. Character of soil ti n Ma a of 3 feedtateSand GraveNo Sa New Constr �tClay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ P ❑ ❑ Y Loam Previous Applica o d • (If yes, 1 Construction: Yes ❑ N FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S�epf�i, Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- No. of compartments---------•---------------Size--------------------------------Liquid clejpt�-- ----------------------Capacity---------------��/,� Disposal Field Distance from nearest well./A_VI.Distance from foundation____/__ _.Distance to nearest lot line_ _S______. iN ❑ Number of lines---.____I---------- _ ength of each line_______ ___ __�J_ -t Width of trench._ ____ e Type of filter material___'_ _.___.._ epth of filter material_____�_f�_______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, Distand-e from nearest"6611Idin _Privy: __. „:Distance from nearest-well--- _""'—�--------------- ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------------------------------------------------------- Remodelin nd or re airin escri e :__-._ r ------ ------- ----- --------- --- -- -------------------------- --------------------------- ------ ----- � ----•--------------•----- -------------------------------------------------- ------------------------------ ----------------------------------------------------------------------------------------•-- -----------------------1 ------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stafe aws, and rules an-1 gulations.of the San Joaquin Local Health District. r (Signe ------- --- -------------------------- -------------------------------------------------------------•----------------._.(Owner and/or Contractorl (Title)_ (Plot p , showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ` FOR DEPARTMENT USE ONLY APPLICATIONREVIEWED BY__ACCEPTED SY-----------------�------------ ---------- --- ----- -----------------._...--__.._.---•-----�--- DATE--------------- --------- --------------------------------- - ._.- DATE-------- .�. BUILDINGPERMIT ISSUED-------------------------------------- ------ ------- — . -- ------ ---• DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------- ------ ------ ------• ----------- --- -------------------••------•----------------------•-----•--•------ ------------ -------------------------------------------------------•-------------------------------------- -- ----------------------------------------------------------------------------------------------------------------------- ` ------------ FINAL INSPECTION BY: Date. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E8-9 REVI6E9 6.59 F.P.CO.2M 6-60 -