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FOR OFF I USE• _ � -- -� -- �r ------ ----- ------------ ------------------ ---------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . .. ._... ..._.../ -------------------------------------------------------- (Complete in Duplicate) Date issued -- -------------------- This Permit Expires 1 Year From Date Issued ............71....... 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. S4,%. JOB ADDRESS ANDOCATION -•- O�.VA�___=_- ---vlz---- r ------- ---•---••----------•---------------------------------------- Owner's Name-- - •..... --•----- ---------------------- --------•-•----------------------------- Phone------------------------------------ Address.----•-.;.0-. - - ----•-----•- ------------------ Contractor's Name----------- ------------------------ ----------------------------------------------------- Phone.........................=......... Installation will serve: Residence &i partment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J.. .Number of bedrooms. Number of baths A. Lot size -------------------_________ Water Supply: Public system ❑ Community system Private ❑ Depth To Water Table 49ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2��ardpan ❑ Previous Application Made: (if yes,date---------_----------) No P-o"rNew Construction: Yes (�o ❑ 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 we .... `"�.___._Distan e prom f`o�uatio ___ �------Mate ial..fr `l _______________. Q�� No. of compar+menu-. ___________ ____Size.>r �__!'�rJ�ce!'_ iquid depth___�°"________Capacity.�, Q _.._. Disposal Field: Distance from nearest well-.--..-- Distance from foundation... / c Distance to nearest lot line--- [V/ Number of lines______ Length of each line_��___r<tl�i ._.Width of trench,,X......--_. y (--- Type of filter material, Depth of filter maferial./Ops�--------Total length.`lo ------------- Seepage _______________________ See a e Pit: Distance to nearest well Distance fr /,q ,�•—r � p g _____ fou ation___.I.LG_..._._..Dis �e #o nearest lot line_Al........... Number of pits------�----------Lining material__ B Size: Diameter_._ -------Depth_A*0 ________________ Cesspool: Distance from nearest well____-------------Distance from foundation--------------------Lining material------------------------------------- 1-1 Size: Diameter-------------------------------------Depfh--••----- ------------------------------------------Liquid Capacity-------------------.........gals. Privy: Distance from nearest well_________________________________________ _____Distance from nearest building____-__-_---_.__-_-..__-______.__..___.._. ❑ Distance to nearest lot line - ------ •-------- Remodeling and/or repairing (describe):-- - ------ ------- - - - -----•---•-•-----•---••----•-•--------...-------•---...--•----.... ----•-----------------------------------------------------------..---------------------------------------------------------------------------------------•--•--------•----------------------------------- --- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and reguia+ions of he San Joaquin Local Health District. W __________________ or Contractor) (Signed)--•---•-----. . ---- --- By:------------------------- — Ti+le - ----- {PIo+ pian, showing size of lot, location of system i ation to wells; buildings, etc., can be placed on reverse side). f FOR D.E ARTMENT USE ONLY APPLICATION ACCEPTED BY./ O •----- -----•---------------------- DATE_.,,,' REVIEWED BY----_------------------ - --------- -------.---------------------- -------------------- DATE----- -._...-----............................. ---------- BUILDINGPERMIT ISSUED__, ---•-•-•------------------------------------------------------------------------------------- DATE---------_----.-------------------------------------------- Alterations and/or recommendations:-------------- ---------------------- --------- ----------•---- .-•-----_-----••---------•-----------------•-•--------------------•------ •---•--•--••--------------------------------------------------------------------------------------------------------------------------------------------------------....................------------------------------------- -------------------------------------- FINAL INSPECTION BDate_ i ------------------------- SA JOAQ N LOCAL HEALTH DISTRICT 1,30 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9'REVISED 8-59 2M 5-62 ATLAS r