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.! FOR OFFICE USE: ------------------a----------------------- -------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in .Duplice+e) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein described. F ;This application is{made in compliance with County Ordinance No. 549. JOB ADDRESS A CATION_ ._' -- -- _ � .. - 1 Owner's Name----- - -- ----- Address ••-Address `------ ---- --------- - --= -- -- - - ---- --- ................ Contractor's Name------------- -•- ----- --- -- -- - --------- Phone----------------------------------- 'Installation will serve: Residence Apartment Ouse El Commercial F] Trailer Court ❑ Motel E3 Other , Number of living units: /---- Number of bedrooms Number f baths _ ___ Lot size ____-/_(�_ _________________ i Water __Supply: Public system ❑ Community system ❑ Priva+e Depth to Water Table __ _____ ft. s Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Loam Clay 0 Adobe ❑ Hardpan ❑ � Previous Application Made: (If yes,date_.._._._..__.__---_) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE4OF INSTALLATION AND SPECIFICATIONS: i (No:septic tank or cesspool permitted if public sewer is available within 200 feet.} - r < Septic nk: Distance from nearest well__------ __Distance from found tions_iq-________Mater'a�_____ _ _ _____ _ C______. I No. of compartments-__________7�__._ Size_ �r?__,r fiquid depth_______��_.____-.-___Capacity_ � I Dispo I Field: Distance from nearest well_Si� -------Distance from foundatioVO4 `-------Distance to nearest lot line-�-________ Number of lines`:_______ _ Length of each line-------- Width of trench.______-�_____________________ ii'------- - �} - fie---- i. 7 ..Type of filter material__ --------Depth of filter material____._ _________Total length------ - _______________--- ;:- _ - Seepage Pit: Distance to nearest well------__--------------Distance from foundation--------------------Distance to nearest lot line_________.______ ( 0 Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------- "� Cesspool: Distance from nearest weil-----------------Distance from foundation____..--------------Lining material-------------------------------------- f0 ❑ Size: Diameter--------- +--------------- ----------Depth----------------------------------------------------Liquid Capacify------------------------- ---gals. (,a . Privy:., Dkstance,from nearest weiL._____.__._---__-______________..__________..Distance from nearest buildingc� I ❑ Distance to nearest lot Gine_________________________ -------------------- ---------------- ----------------------------- deling and/or repairing (descritb-e):------------------------- ----------- --------------•---•---------------•------------•----------------------- i Remo i ------------------------------------------------------------------------------------------------------------------------ -------- l -------,---�--------------------------- ------ -------------------------------------------------------------•------------ ------------------------------------------------••---------------------•--------------------------------- -------------------. . .----- I`hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Court r ordinances, State la , and rules and regulations o San Joaquin Local Health District. I [Signed} ------t 0-1 n- - ------------ a d/or Contractor) BY ---- ---- --------------- ---(Ti+le)------------------- ----------------- ------- --------------- (Plo+ plan, showin ae of to+, Iota+ion of system in re #ion +o wells ildings, etc., can be placed on reverse side). i E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___. -- -- - - ------------------------------------ ------------------- DATE---f�__"•�--'��--�-- -------------------- ------- ,�'�. REVIEWEDBY------------------------------------------------------- --------------------------------------------------------------------- DATE------------------ - -------------------- BUILDING PERMIT ISSUED---------------------------------- ------------------ ------------------------------. DATE---------------------- Alterations and/or recommendations: - -----------------------------------------------------------•----------- •-------------- , -----------I----------------------------------------------------------------------- ---------------------------- -----------------------------------------•-- -------------------------------------•-----------•-------------- ---------- --------------------------------- -•--------------------------- - ------------------------------------------------------------------------------ -------------------------------------- -------------------------- --------------------- ----------------------------------------------------•---------- ----------------------------------•---------------•---------- •---- -•--------- --------------------------- FINAL INSPECTION BY., Y --- ------------------- Date-- ---�- --- �------- -------- ----------- - - ------- r - SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street t t r Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-•63 F.F.CO.