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FOR OFFICE USE: ------------------------------ -------------------- 7 --------------------------------------------------------- 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 d scribed. This application is made in compliance with County Ordinance No. 549. 41 JOB ADDRESS AND1 LOCATIONS r Q� -"` i� Owner's Name •------------ ------------------------- --- ---------------------------------- Phone- ------------- -------------- Address. �11 -f----- re --------------•-------------------------•---••----------------------------- Contractor's s Name----- --Residence ---------------- -------------------------------------------------------- Phone------------------ ❑ Apartment House ❑ Commercial ❑ Trailer urt [3 Motel [:] Other 1 Number of living units: ________ Number of bedrooms ________ Number of bath__._-. of size :31�_QiG -___.__ ________________ Water Supply: Public system [] Community system ❑ Private jif Depth to Water Table/a7__ ff. 11 Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan [] Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: CA (No septic tank or cesspool permitted if public sewer is availa6le within 200 feet.) (� JSe tic Tank: Distance from nearest well---------_------Distance from foundation__._______-_-_-__.Material______________________________________________-. v No. of compartments--------------------------Size----------------------------•---Liquid depth--------------------------Capacity----------------------- � Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line_____--_-_-______ Number of lines-----------------------------------Length of each line---------------_-------------.Width of trench.-------------.------------------ --- Type of filter material-------------------------Depth of filter material-----------------------Total length-------------------------------__-------- See a _______Seepa a Pit: Distance to nearest well--- s__-------Distanc rom oundation_ _Q_�__.__.D,istance to nearest lot line__.5_-___.._ Number of pits____ _______________Lining material_ .__.Size: Diameter_5 �� Depth__ _.-.____________-__-____ Cesspool: Distance from nearest well_____________-__Distance from foundation--------------------Lining material--------._._______..____________---_ ❑ Size: Diameter------------------------------------1 Dept h------------------------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------i--------------------------------Distance from nearest building-------------------------___-_.__.._-__._. ❑ Distance to nearest,lot iline- `'-'-------f------------------------------------------------------ -------------------- ------------------------------------------------- Remodeling and/or repairing (describe)-----------------------` ----- --------------------- --------------------------------------•----------•-------------------------------------------------------------------------•--_------------•-------•------------------- ---------------------------------------------------- ------------- -----------------------------------------•----------------------- ---------------------------------------------•--------------------------------------------------------------------------------------------- -- -------------------------------------------------------------------------------------- ---------------------------------------------------•------------------------------------------------------------------------------- I hereby fy that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S ate aws, and rules and regulations of the San Joaquin Local Health District. --- ner and/or------------ (Signed) Cantrac#or Title ----------- -- (Plot plan, showing size of lot, location of system in relation to wells, 6uildings, etc., can 6e placed on reverse side). — r� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------1.#-tR-_0t----------------«----------------------------------------------------- DATE----- a �_"_.----•�--- -- --------------------------- REVIEWEDBY---------------------- --------- --------------------------------- --------------- ------------•-•---------------------- DATE--I--------•--------------- BUILDING PERMIT ISSUED-------------------------------- f.,, . _�. - I------------------ DA•TE Alterations and/or recommendations:------------------0------------- Ii --------- - - ------ --------------------------------------------------------------- ---------------------------- l c FINAL INSPECT N BY Date........._.�J__.`_3------- . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 3M 3-'63 F.P.CD.