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�VOR OFFICE USE: l , �--- ------- APPLICATION FOR SANITATION PERMIT Perm;t No. � .�� --- ` ----------------------- G------ -------- --------- in Duplicate) /G��/ ------------------------ (Complete p ) Date Issued._-•---------•--------� _ _. is rmit Expires t Year From Date Issued Application is hereby made to t e S mLocal Health District for a permit to construct and install the work herein describe This application is made in comp ian *i ntyy Ordinance No. S49. J08 ADDRESS AND LOCATION --------•-- ....!1.- --- Phone--------------------------- -------- I1= Owner s Name___." " - Address----------- ,�-�---- a't ------•------------ --- -----._-------------------•-------- Contractor's Name-----� .Y ----------•------------------------------- ------------------------------•-----•----------•-••- Phone........ ---_--------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.I___ Number of bedrooms -_ Number of baths _1.____ Lot size ,P_sCf/D----------------------------------------- Water ----____.__Water Supply: Public system ga—Community system ❑ Private ❑ Depth to Water Table --- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Gay Loam ❑ Clay ❑ Adobe[Hardpan ❑ Previous Application Made: [if yes,date--------------------) No [r New Construction: Yes 21"-No ❑ FHA/VA: Yes ❑ No 25--1 TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Material__j`--------- -------------- ----------- Septic Tank: Distance from nearest well___- ---Distance from foundation��__-______.__ Capacity__._ No. of compartments------ .........Size----'3 ` Y �-=---Liquidd epth__4---------- �`-1 .__ — c Disposal Field: +' Distance from nearest well___' _.____"Distance from foundationnl0_ ___________Distance to nearest loft line________ ______" Number of lines---l'_.-�--- -------------Lenpgth of each line__5a_---------------------Width of trench ------:--------------------- Type of filter matena__I._�:�-��---- --De th of filter material----- -------------dotal kength---_. .-----=---•------ _____Distanc from foundation__�D_..___..__..Distance to nearest lot line----------------- 6' Seepage Pit: Distance to nearest well__._______ a Lining material._/ -aG -------.Size: Diameter__.33- ------Depth_ CF-.--- Number of pits--�---------------- - Cesspool: Distance from nearest well-----------------Distance from foundation------ -----------_Lining materia------- ..______________ t Depth ----------------Liquid Capacity gals. � Size: Diameter-------- ---------- ---------- - Privy-. Distance from nearest well__________________________ ----Distance from nearest-building-------------------------------------- -r.. ❑ a, Distance to neares# lot line-------------------------- --------------------------- -------------------------------------------------------------- Remodeling and/or repairing (descr"ssl,e):----- ------------------------------------------------------------------------"•-------------------------------------------------------•--------------- ----------------------------------------- --------------------------------- ---------------------------- -------- - --- ---- -- -------------------------------------------•-----------------•--------------••----------•--------------------------------------------------------------------.----------------- ---- I hereby certify that I have prepared this ap I" at* and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulatio s f th San Joa in Local Health District. (Owner and/or Contractor) (Signed). By:----------- ------------------- ---------- ----------7----- ------------------------------- Title --------------------------------------- ---------------------- (Plot plan, showing size of lot, location of system in relationrto wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY '�� DATE.---- `� ^'' - i DATE_ REVIEWEDBY--------------------------------------------- _ BUILDINGPERMIT ISSUED---------------------------------------------------------------- --------- Alterati ns and/or recornmen at ons: -------------------•-- - -------------- , 4 ------------ _._.._-__ _____- r 4 1 ._..--____•____•___--_____•_____ flS-- c� ---------- ---- -------------------- ------ - i FINAL INSPECTION BY:----------� �. �4-'--------- ------------------ " Date----- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVfsED 8-59 3M 3-'63 F.P.CO.