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FOR OFFICE USE: -------------------=' -------------- ----------------- -------------------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. ----------------- ----------------------------- (Complete in Duplicate) --121fcl -----------------_._.._--------------.-_.-___--_.___.__. This Permit Expires 1 Year From Date Issued 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 incompliance with County Ordinance No. 549. r-� I�k 1 ` k - - -- ----i-- g y �� = JOB ADORES AN OCATION_-- - Owner's Name------ ----- ---- ----------- ------------•------------------------------------------------- Phone....... --------------------------- --------------- Address ---------- Address-----...-�p--- - ` - -•-•------------ fJ.-_.. --. -------------------------------------_------------•----------- ---------- Contractor's Name I� __rl_, :- ...._. --- ------ Phone....._.. Installation will serve: Residence [Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms ___f-_. Number of baths ___I{___ Lot size ----1-44-13-14-2_ ___ ________________ Water Supply: Public system ❑ Community system ❑ Private [6 Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [r Previous Application Made: (If yes,dote.................----) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND,SPECIFICATIONSc (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r' Septic Tank: Distance from nearest well----------_------Distance from foundation----------------_.Material -------_.---------------------------.___.____- ❑ No. of compartments------------ ------------Size---------------------------- ---Liquid depth--------------------------Capacity-•--------- ------ Z , Dispos I-Field: Distance from nearest well-_�Z'_�_.__Distance from foundation. --------- to nearest lot line__5..�_.____ Number of lines---------------i------------------Length of each line------t7.j---------------Width of trench------X. ---------------------- Type of filter material______s. _9--------_Depth of filter material----1_ ------------Total length------1.7---------------------- _____ (+i % b Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_._____________-_ ❑ Number of pits----•-----------------Lining material-----------------.-.---Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material------------------------------------- ❑ Size: Diameter------- ------------------------------Depth---------------------------,-----------------------Liquid Capacity- .----------------------...gals. Privy: Distance from nearest well _________________________----------------------Distance from nearest building._____________.__------- ---- Distanceto nearest lot line-- ---------------------- -- ------------------------::------------- ---- ----------------------------•---------------- - -I--------- Remodeling and/or repairing (describe):--------10-9.............'---------------------------- /---------------------•------------------------ ---------------------------------- ------------------------------------------------------------ .-----------------------•--------------------•-------------------------•---------------------- ------ --------------------•---------------------•--`----------------------- ------------------------------------------------------ ------ ------------------------------------------•f y __ --------------------------------------------- _ _ ------- ------------------------- - --- --- ------------------------------------------------- --------------------- -------------• ---------- •-- ---- ---------------------------------------- I hereby certify that--------------------------------------------------------- Ihave prepared this application and that the work will-be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of_'t�n Joaquin Local Health District. '' __- r-and or Contractor Signed)--- 1 BY� _ ---------- -------------------------------------------------------(Title)----- -- ----------------------------- ---- - (Piot plan, showing size,of-lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----------------------------------•----------- DATE-- rel ------- REVIEWEDBY------------------------------------------------------------- ------------------ --------------------------------------------.. DATE-----------------------------------------------•------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------- ------------------- DATE------------------------ ------ Alterationsand/or recommendations:-------------------------------------------------------------------------------•---------------•-••----------------------------•----------------------------- t[, .: l ----------------------------_______________________.-----------------.-------------------------------------------------------------------------------------------------------------.-.--------------.------------------ ____.__ w FINAL INSPECTION BY:__ ------------------ ,�? ---" - Date------.. -- y -------------------------------- -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 E5 9 REVISED 0.59 31A 3-'63 F.P.CD.