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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .. ................. -- --------- ---------------------------------------- - - (Complete in Duplicate) Xr Date Issued This Permit Expires 1 Year From Date Issued .6' r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install f e work pheoreirclescribed. This application is made in compliance with County Ordinance No. 549. 3(,(,c)_, ,d / JOB ADDRESS AND OCATI N-- F? ----• -------------------------------------- Owner's Name----- ---- ---•-------------------- ----------- -----._. Phone------------------------------------ ---------------------- ---••----------------- ----- - --------------------------------------------- - Address - ' ... ------ Contractor's Name----------------------- ------------------------------------ ------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___j____ Number of bedrooms __ ___ Number of baths __j----- Lot size __.- _R?!u'? _______________________________________ Water Supply: Public system ❑ Community system ❑ Private L� Depth to Water Table _4__P_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam k] Clay ❑ Adobe ❑ Hardpan II Prevyous Application Made: (If yes,date--------------------) No (? New Construction: Yes ® No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----_------------Distance from foundation--------------------Material--------------------------------r_-------____.____- ❑ No. of compartments--------------------------Size---------------•------------ ---Liquid depth--••----------------------Capacity--------------------- 6. Disposal 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 Pit: Distance to nearest well--/-------------Distance from oundation_1�_________-Distance to nearest lot €ine_.�--------- Number of pits____J---------------Lining material--_J ------.Size: Diameter____3_a'..........Depth----Ya_----------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______.___-_____-______-_-_____._ 'a 7 ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Priv Distance from nearest well-------------------------------------------------- from nearest building ----------------.I;IIF ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------u�r` '/�'L-` 1------- -v G`"r "----- 9� ----------------------------- -----------------------•---------------------••------------------------------------------------------------------------------------------------------------------- ------------------------- 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. _Y (Signed)--------- L, l� --------------------------------------- -------------- - -------(Owner and/or Contractor( By:------------------------------------------------------------------ -----------------------------------------------------------------(Title)------- --------------- --------- ----- - -- -- ---- -------- (Plot plan, showing size of ]of, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - !1�,0- ------ ---------------------------------------------------------- DATE-- - � �'�------ REVIEWEDBY--------------- ----------------------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--- ----------------------------------- ------------------------------------------------------------- DATE------------------------------------ --- l ------------------------- ---- Alterationsand/or recommendations:-------- ------------------------------------------------- ------------------------------------------------------------------------------------------------ ---•---------------I---------•---------------•----•---------------------------------------------------------------- - --------------------------------•---- ---------------------------------------•-------------- ---------------------------------•------------------------'------------------------- ---------- -----------------------------------------------------•--•-------------------------------------------------------------------- FINAL INSPECTION BY _ .- _ - ---------------------- Date----17__-2_3---_6 r --------------------------- ------ ---- --------- 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 8-59 31A 3-'63 F.P.CD.