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FOROFFICE USE: .oyu ---- -- - --------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.(Complete in in Duplicate) -------------- This Permit Expires 1 Year From Date Issued Date Issued ____I`__,___ � 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 No.. 55449. JOB ADDRESS AND OCATION._' e---- ------------ ---}`-, - ----4----------------- Owner's Name--- --- --------------- ----------------- -------- - Phone.-------------------•------•--- Address------------- --- �� Z Contractor's Name__-� .cnk .a�---�.__.�f___�------- =---------------------------•---------•------•--- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __!____ Number of bedrooms --,3- Number o baths _� Lot size ----- - - - _______ Water Supply: Public system E] Community system E] Private Depth to Water Table _ --____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam RT Clay ❑ Adobe 0 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.) r Septic Tank: Distance from nearest well_________________Distance from foundation-------------------Material---------------- ___._______-____.________- ❑ No, of compartments--------------------------Size------------------------------•.Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_______________-- m ❑ Number of lines-----------------------------------Length of each line----------------------------.Width of trench----------------------------------- (� Type af•filter material-------------------------Depth of filter material----------------------- otal length___________-_______-___________________-- by See a e Pit: Distance to nearest well_-__- -�� _ 'f`_Dlstance from foundation____ e to nearest lot F Nutmber of pits--------/------------ material--S _..___.Size: Diameter--------7_.�`�__.Depth_____�rf________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 11 Size: Diameter------------------------------------ Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____________------_____________._____.._. A ❑ Distance to nearest lot line____________________ r F Remodeling and/or repairing!(describe):-------- ------------------- ---------------------------------------------------------------------- -------------------------•------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.---------------------------------------- -------------------------------------------------------•-------------------I•---------------------------------- — ------------------------------------------------------------------------------- ------------------------------ 3 A 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)------------------------ --- ----------- �nai�and/or Contractor) By:--------------------- -------- - - t ----- ----------- -- ------ (Title)----- --. -- ----- ----- ------- --- (Plot plan, showing size of lot, location of system in relation to yells,-buildings,etc.;can°be placed on reverse side). Q 5 1 FOR DEPARTMENT USE ONLY z d APPLICATION ACCEPTED BY---- - -- -- - ---- - ----------------------------------•---•------------ DATE----- - - --�--- ----- ---------------------------------- REVIEWEDBY------------------------------------------- - --- --------------- ---------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------ Alterations and/or recommendations:----------------------------- -------------------------------------------------------------------•---------------•-------------•------------------------------- ---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ --------------------------- ------------------------------------ ----------------- •------- ----------------------------------------------•-------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:..- �( � b - 0/.r ��= �""� - Date " f----------- ------- -•----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3•'63 F.P.CO.