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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 Up. 549. JOB ADDRESS AND CATION �a P�f `-' OU-x, � '---------•-------------------------- Owner's Na E Phone.................. • Address Q Contractor's Name------- ------ Phone___________________---------------- Installation ______ _Installation will serve: Residence ❑ Apartment House Commercial ElTrailer Court. ❑ Motel [_1Other E]Number of living units: __._ Number of bedrooms ___ ___ Number of baths I----- Lot size .......... Water Supply: Public system ❑ Community system ❑ Private ff-..'Depth to Water Table -------- ft. Character of soil to a depth of.3.feet: 'Sand ❑ Gravel ❑ Sandy Loam ffrclay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date__F --------------) 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_________________Distance from foundation--------------------Material-------------------------I---___________________- ❑ No. of compartment'--------------------------Size_.-_--------------•------_Liquid depth--------------- ---------Capacity--...----------------- Number of lines___._. ' Dis os� ield: Distance from nearest weli--. 4_-f--Distance from foundation__�O___._____.__.Distance to nearest lot line__-"*..... p � �_ ._ Length of each line_______�•CJ__f'__«_____.Wid#h of trench-------z____ Type of filter mateial__ _ __ __ _____Depth of filter material______tL----------Total length----------/__t _Q_________________.__. Seepage Pit: Distance to nearest;well----------------------Distance from foundation________________.-..Distance to nearest lot line__________.___-_ 3 ❑ Number of pits------i------------- Lining material-----------------------Size: Diameter-----------------------Depth-----------------------------.... Ib 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------------------------------------------ ElDistance to nearest lot line-_------------------------------------------------------------------I---------------------------------------------------------------------- Remodeling and/or repairing (describe):----------- ------------------- ---------------------------------------• f-!�A ----------- ------------------------------------- ----•--------------- • •------------------- -•-•---------•-----------------•------------------------------•-----------------------•---------------------------------- I hereby certif hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws and rules and roe a San Joaquin Local Health District. (Signed)------------ ---- ----------------- ------- --- ------ ----- -- ------ -- ------------------------------------ ----------------------------- and/or Contractor) E3y:.- Title----------------------- ---------- ................... -------- (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). _ i FOR DEPARTMENT USE ONLY tt�� APPLICATION ACCEPTED BY----- DATE- --A---/1�.`_ -. REVIEWEDBY------------------------•------------ ----- DATE---------------------------- ----------- BUILDING PERMIT ISSUED--------------------------------------- --------- --------------------------------------------------- DATE----------------------------------------------------- Alterations and/or recommendations:---------•--------------------------------------------------------------------------------------------•------------------------- ----------------------------- -------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ -------•-------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ FINAL_ INSPECTION BY: Date. .' ' - ------ ----- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3-'63 F.P.CO.