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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 1 e.1. .. --------------------------------------------------------- -.... ---------- --------------------------- -- --------------- (Complete in Duplicate) Date Issued ._.- ' ------------------------------------------------- This Permit Expires 1 Year From 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 in compliance with County Ordinance No. 549. �f Q JOB ADDRESS AND LOCATION---�- --�--�--Z ---------f `-------� .....----_=_9_1----------------------------- ----------------------------- Owner's Name------- t----- , ---t-------� --------------- -------------------------------------------- Phone------------------------------------ Address - -- - -----------------------------•--------------------•------------ --------------------------------------------------------------------------------- I Contractor's Nama-------------- - --- -• - - -_-- -- ...--- _ -• .- ---'------------------------•----------------------•-----------•---•---- Phone.9�6A---- 4 0.7----- Installation will serve: Residence .7 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�_____ Number of bedrooms _��__ Number of baths ____/__ Lot size ------ ----------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table 6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,9 Hardpan ❑ Previous Application Made: {lf yes,date-----------.--------1 No [ New Construction: Yes ❑ NoA FHA/VA: Yes ❑ No3' 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 _______________.._____...________..______-_-_ ❑ 4 . No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity------------•------ Disposal Field: Distance from nearest well....b-V_'___Distance from foundation------)_O__'.....Distance to nearest lot line___._. Number of iines--------1-------______ __ _________Length of each line-----------------------Width of french-------2-_�_�� Type of filter material___�!_,�_o-l�Depth of filter material__________�__��.Total length_______________________�_C3_.r_.__-- Seepage Pit: Distance to nearest well----------------------Distance from foundation---..._-.-----------Distance to nearest lot line__-__-.__________ J ❑ Number of pits----------------------Lining material-----------------------Slie: Diameter------------.----------Depth--------------------------------- 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_____.____._______-_-_____-____._____--- i ❑ Distance to nearest lot line- -----------------�--'-------------------------f----------------------------------------•------- ----------------------------------------------- Remodeling and/or repairing (describe):----r.- •r4Z1 .--- --- - ---- -------------------I- —--------- --------------------- •------------------------------------•------------- -------------------------------------------------------------------------------- -------- --------------------------------------------------------------------------------------•--------------------------:_.---° --- -----------------------------------------------------------------•------------- - ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed---------- C' '� -------- ----------------------------------------------------- ( ner and/or Contractor) By------------ ----------------- - - -`- ^' (Ti+le) (Plot plan, showing size of lot, location of system n relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----f J y ----------------------------- DATE----------- - --xl -------- REVIEWEDBY------------------------------------ ----------------------------------- ---------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------- --------------------------------------------------–------------------------------------- DATE___--------------------------------------------------------- Alterationsand/or recommendations:--------------- ---------- --- ------ ---------------•-------------------------------------------•--------------------•--------------------------------------- ----------------.-___-_-------------------------------------•--------•------ ------ -----------------------------•----------------------------------------------------------------------------------------- ----------------------- ---------------------------------------- ------- -------------------------------------------------._..----------------------------------------------------------------------•------------------------- --------------------------------------- ------ --------•- ------------------------ -------------- --------------------------------------------------------------------------------=�7----------------------------------------- - -------------------------------------- ------ - --------------- ---------------------------------------..--.._..------------------------------------------------------------------ ------- ---------- lop3 FINAL INSPECTION BY: - ---- ---------------- Date----- ----�.!__. _ SAN J QUIN LOCAL HEALTH DISTRICT 1601 E.Ha:*lton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,CalfFornia Lodi,California Manteca,California Tracy,California E5 9 REVi5E0 B-59 3M 3-'63 F.P.CO. t