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APPLICATION FOR' SANITATION PERMIT Permit No. J.A-3.2__-__ Complete in Duplicate) G 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. f This application is made in compliance with County Ordinance No. 549. it JOB ADDRESS AND LOCATION---- -4--------------- ----------------------------------------------�-------------- --------•-•• •--- --------------- iA r Owner's Name----9W4---7 ) Phone------------------------• --------- Address .. e ;.0.�....... -------------------------------------------------------------•-•-----•----•- Contractor's Name---Q .e 5----•-----------•---------•-------•-----------------------------------------••--•------------••--____ Phone-ma--- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel J� ther ❑ Number of living units: __, __ Number of bedrooms _ ___ Number of baths ,3___ Lot size --- ----------------------------- PZ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table Clsaracter of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p Clay ❑ Adobe 91--Hardpan ❑ Previous Application Made: Yes ❑I No [L] -'-New Construction: Yes Ed�No ❑ FHA/VA: Yes ❑ No R;j' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic T�w' Distance from nearest well-----------------Distance from foundation--------------------Material-____-____:___-__________-__________"_________- No. of compartments--------------------------Size-------------------------------_Liquid depth------------ -:-----------Capacity----------------------- Dis sal 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------------------------------------------ Seepage -----------_----:--------�-------- Seepage #: Distance to nearest well--�-Q-q-----------Distance fr fou dation__rzts_--_"___.Dista37to nearest lot line______"_______-__ Number of pits--------I__________Lining material___n _ .Size: Diameter-----'5'f_.-Y_"-____Depth------- ---_____"-----__ I 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 ----------------------- ----- ❑ � Distance to nearest lot line----- -------------- ----------------------------------------------•---------------------------------------------------------------------- Remodeling ---- - - ---------Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------------------------------•----------------------------------------------•-------------------------------------------- ---------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State lawsdand ule and regula+ions of the San Joaquin Local Health Distric+. (Signed)------------- ------• - - ---------------------------------------------------- ---- (Owner and/or Contractor) Title - --------------- By:----------- { } (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can..be placed on reverse side). `n ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- DATE---_ ------ ,_---_ ------------------------------------------------------- - ------------------------ REVIEWEDBY----------------------------------- ------------ --------------------------------------------- DATE---------------- --•----------------------------- ( BUILDING PERMIT ISSUED-------------- DATE----------•------------------------------------------------- Alterations and/or recommendations:-- ----- ---------------- -- -------------•--•------------------------------------•-•---------------------•-------------------------------- --------------I------------------------------------------------------- -------•----------------------------------------------------------------------------------- -------- ----------------------------------------------------------------------------------------------------------------------- --------------------- t -----•-- -----------------------------------------------•------------ ---------------------------------------------------------------------------------------------•-- ----•-------------- ----- --------------------------- -----------------•----•-- ---------------------------- ----------- ----_-_---------------------------. ------------------------------------------- ----------------------------------------------------"- --------------- - ------------I----------- -------- --•-------------"----------- ----------------------------------•----------------------------------------------- 2-3 -LI" FINALINSPECTION BY:---------- ---- ---------------------------------------------- Date--------------------------------- ---------------------------------------------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California • ti. Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 F.P.Co. __