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FOR OFFICE USE: - o{ _- ----------------------------------------------- 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION - --- --------- ---- _-------------- Owner's Name------, ---- - - � 1-- ------------- Phone-----------•------------------••- Address-----------------lis ........... 1.__1P •----- ----------------------------------------------------------------------------- Contractor's Name-------Ai r.'p.1-4.--......-.......--------------------------------------------------------------------- ---•-- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trail e Motel ❑ Other ❑ Number of living units: -1---- Number of bedrooms -1----- Number of baths I.-- Lot size -----_.--____---_--------.- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4-0- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy+Loam,[ Clay Loam Z 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 Tank: Distance from nearest well--rl--Q_--- Distance from foundation--.�d-__-.___.Material-- ----------------- --- f - ------------------- k No. of compartments---Z-----------------Size 4 � t- _t--r----Liquid depth----. ---`------.-----.---Capacity.1o_2-&V---I- Disposal Field: Distance from nearest well-.r#.........Distance from foundati n_ 0-------------Distance to nearest lot Gne_ --------------- Number ----.-_-. Number of lines------ - .-- -- Length of each line----- _b- -----------Width of trench,.�---'y-�--------------------- Type of filter materiae Depth of filter material------/?--* -----..Total length__A! *_�--------------_---------._ }� Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----- C1 --.--------- F1Number of pits----------------------Lining material-----------------------Size: Diameter----•------------------Depth--------------------------------- i` Cesspool: Distance from nearest well-----------------Distance from foundation------------------. Lining material--------------.---------------.--------------------------------- 11 17-1 Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well---.-____------------------------_---------- --Distance from nearest building------------------------------------------ P ❑ Distance to nearest lot line-------------------------------------------- ------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------•--•--------------------------------------•------------------•---------------------------------------------------------------------------------------- ------------------------ -----------------------------•--•-----------------------------------•----------------------------------------------------------------------------------------------------------------------- ...... . r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ;tatews, and rules and r gula.ions of the San Joaquin Local Health District. Z(Signed).----- _--- - ----- y = - -----. ----------------_Y .. -_- __: [Owner and/or Contractor) By:-------•--------------------------------------------------------------------------------------------------------------- --- -----(Title)------- -- --------------------- - (Plot plan, showing size of lot, location of system in relation to,wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY' ------ _ DATE cSr ' 5l - REVIEWED BY_--------------------------------------------------------- - _------------------------------------------------------------- DATE-------- ---- BUILDINGPERMIT ISSUED-------------------------------------------------- ----------------------------------------------- -• DATE------------------------------------------------- ------- Alterations and/or recommendations--------------------------- -- ------ ---------------------•----------------------------------------------------------------•------ --------------------------- ----- ---------------------------------------•----------•---------------------------------------------------------- - ------------------------------------------------------------•----•-------------------------- ----- ---------- --------------------------------------- ---•-- ---------------------------- ----------=------ -----------------•-••-•----------•---------------------------------------------------------- FINAL INSPECTION BY -----. -- - -- -� ---- -- - ----------------------- Date--- -- _l.-.+ --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E.Hoxelton Ave. 300 West Oak Street ► 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 NM 3-'Sn r•.P.Dp.