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FOR OFFICE USE- ---- --------------- --------------------------------- APPLICATION SE-------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...1 �...--- ---- ------ -------- --------- --------- (Complete in Duplicate) Date Issued ---<� -----------------------------------------_____--_----_-- i 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 Co my Ordinance No. S49. JOB ADDRESS A "LOCATION_ G1_ _j %p------------� Owner's Na ------------- ---- ---- ----•-•---------•-- ------- Phone----------_-------------------•--- - ------- ---- ---------------------- Address------------------ -�/ ._.--- - 1—- ------- ----- ----- r b Contractor's Name �•-4-�-�• _ r' Phone ••---- --- ---- Installation will serve: Residence Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ Number of bedrooms--_ Number baths.__- Lot size __________________________ ____ _______-_._.___-._ Water Supply: Public system ❑ Community system ❑ Private Depth to Water. Table .-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel p Sandy Loam ❑ Clay Loam Rr Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes 21""No'❑ FHA/VA: Yes l-'7 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well__4�.......Distance from rm foundation_ V__� -__-_-__.Material----------------------- -_______--------------- No. of compartments-----7��------- - -- Size- '- � S!ii uid de th------ -- -----------Ca aci dG Dispo Field: Distance from nearest w:••e�ll-_., �' --_._Distance from foundation-----44-_l.----Distance to nearest lot line ___________ Number of lines--------- 3_____. _ Length of each line___vla�_---------------Width of trench_-..-`.Z._________ Type of filtermatenal_____ I __f__Depth of filter materia------- -_-___-__Total length------- _ _6___________________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line_____-_-_____-_. C" ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth-_------------------------------. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------- ____--__❑ Size: Diameter--------•-----------------------------Depth--- ------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------,--___-___-_. ❑ Distance to nearest lot line- -----------------------------------------------------------•-•-------------- -------------------------------------------------------------- Remodelingand/or repairing sc abe):----------------------------------------------•--------•--------------------•-----•--•----------------------------------------•-----------------------• . - )------------------------•------------------------ ------- ------------•-----------------•-------------------------------------------••----------------------- ----------------------------------------------------- ----------------------•----------:- ---------------------------------- ----------------------------------------------•------ -----------------------------------------------------------------------------'•---------------------------------------------------------- -- I hereby certify that I e prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, s and regulations of the San Joaquin Local Health District. - V (Signed) ----- ---- ---------------------------------(mac and/or Contractor) -----(Title)------ ------------ ---- ---------------- By: --------------- --------- (Plot plan, showing size of lot, location of system in relation to wells, bu Ings, etc., can be placed on reverse side). / FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-�- s �� - DATE__ �-------------------------------------- -- REVIEWEDBY-------------------- -------------------------- ----------- -------------------------•--------------------------------------- DATE--------------------------------'-•-•----------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------- ----------------- Alterationsand/or recommendations:------ ----------- -------- ------------------ ----------------------------------------•------•-----------------•--------------------•------------------------- --------------------------------------------------------------------------------------------------------------------------------------------•---------------------------- --•-••_---------------- ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------------------------------------------- -------------------------------- •-------------•------------------------------------------------------ - -----------------------------•-------- ---------------------------------------------------------------------------------------------- ----------------------------------------------- -� f FINAL INSPECTION BY._._ ' ___ }_'f ---------------------- Date_.. --- ------ -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED M-59 3M 3-'63 F.P.CO.