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FOR OFFICE USE; ------------------------------------------------------ APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------- (Complete in Duplicate) ------------------------------------- -.----__------.--_ This Permit Expires 1 Year From Date Issued Data 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 No. 549. JOB ADDRESS AND LOCATION/ ? - r F Owner's Name Phone._..... „ ----------- ---------- - Address---...... �� o -=r �� e T - c y v .� Contractor's Name---------6.-- -- -- �- _.-je".....-a/ ----------- Phone----••-•------------- Installation will serve: Residence wApartmenf House ❑ Commercial ❑ Trailer Court [I Motel ❑ Other ❑ Number of living units: _I"----- Number of bedrooms %_._ Number baths __/__ Lot size ....... ----__-----------_ ___________________ Water Supply: Public system E] Community system [I Private Number t Water Table -------- ft. Character of soil to a depth of 3.feet: Sand E] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ I Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material____-----------__-_---_-___________-_-_---_---. ❑ No. of compartments--------------------------Size-------------------------------Liquid dent --------------------------Capacity----------------------- Dispos Field: Distance from nearest well--„ ._____Distance from foundation----_�d-------Distance to nearest lot line----------------- Number of lines-----------/________ ____________Length of each _--_--.-_.Width of trench.____�__--___-__-------------- ""Type of filter material_ /Z_________Depth.of.filter.material_________�_S_��._Total length__,-__--_---1,V,0-�______________ 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-,---------------------------------- ib ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------------------ -gals. 1 Privy: Distance from nearest well______.___y______________---______._.--___-___._`Distance from nearest building-------__-._____-_________________.______- ❑ Distance to nearest lot line-.___--------------------,_.,--------------------------------------------- Remodeling and/or repairing (describe)----------------------- -----------------------••----•-----------------•- --------- -- -------------------------•-------------------- -----• i �- ----------------•-••-----------------------------•------------•--------------------------------------•------------------------------------------------------------------------------------------------------------------ A ------------------------------------------------------•---------------••--------------------•-------------•---------------------------------------------------- -------------------------------------------------------------- I hereby certify fh I have prepared this application and that the work will be done in accordance with San Joaquin County o ordinances, State laws, aL regulations of a San Joaquin Local Health District. and or Contractor . (Signed) � / is -- ---- -----------I----- � ------------- (Title) (Plot plan, showing size of lot, location of system in relation to wells,��,Idings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- DATE- REVIEWED BY---------------------------•---- -------•---- - ----------------------- ---------------- DATE---•-------------------- - - --- - -------•--------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------•--------------------------------------------- DATE----------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------------•-----•---------------------- ----- -•------- ----------------------------------------------•-.-------------------------------------------------------------------------------------------------------------------------•-------------------------------- ----------------------------------------------------------------/---------------------------------------------- ----------------------------------------.--------------------------------------------- ---------------- FINAL INSPECTION ��---------------•----- 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 ES 9 REVISED B-59 3M 3-'63 F.P.CD. i