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R OFFICE USE: ' ------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ___1..7777 ---------- -------------------------------------------------------------- (Complete in Duplicate) �2 G Date Issued --------------------------------------------------------- This Permit Expires 1 Year From pate 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. s JOB ADDRESS AND LOCATION--- �► .� ....1 ----------- __7 -% <_G s •1:.�'d,sz _ -_�t_ � Owner's Name/--�--- --- ------- ---- ----------------------------------------- -- - ----------------- Phone__....-_. _ ..Address - �Contractor's Name------------ - - - ------------------------------------------------- ------------------------------------ ------------------ Phone------•---------------- Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ----lF-- Number of bedrooms -'1----- Number of baths ----- Lot sizey_________ __y _ _________________________________ 1 Water Supply: Public system ❑ Community system ❑ Private [ Dep+h +o•Wa+er Table -ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ' Clay ❑ Adobe [y Hardpan Previous Application Made: (if yes,date------- -------- --- J Neu"` New Construction: Yes, FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Sep�Tank�'�, Distance from nearest well-----------------Distance from foundation--------------------Material-----------------------.-------.-------___._____- I 'No. of compartments----- _ _____ ____________Size--------------------------------Liuid de th___-.__-__._____._________Capacity Dispo al Field: Distance from nearest well---0 ____Distance from found ion...-_ ....._.Qistance to nearest lot Number of lines-______-�(-____________________ Length of each line_ -- _(t Width of trench______r _r____ Type of filter material,,57 ___ _ _Depth of filter material____._4 ____-Notal length________ � • ---------•----••---- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.__.___________ ❑ Number of pits----------------------Lining material------------------ ----Size: 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__________-_____________________.---__.._.,+►+ ❑ Distance to nearest lot line----------------- --------------------------- --------------------------------------- 0 Remodeling and/or repairing (describe)'------- ---------------------------------------------------------------------------------------•--------------------------------------------------------O --•------•---•-----------------•----------------------------------------------•------------------------------------------------------------------------------- ----------------------•--------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------=-------------------------------------------------------------••----------------------------------- ---------------------------- --------------------------••------------------ - ---------- I hereby certify thZarnrules ve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and regulations of the San Joaquin Local Health District. O� (Signed) --- --�/---- ._____Owner and/or Contractor By:-----------------------------------------------------------------------------------------------------------------------------------(Title)----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION BY_ ACCEPTED BY---------------- -------- --------- - - -- .-�--- -P ----------------------. DATE--------------- ---------- ---------------=------------ - - ----------------------- DATE---- BUILDING PERMIT ISSUED---------------------------------------------- ---- ---------------• DATE------------------------ -- Alterations and/or recommendations--------------------------------- -------------------------------------------------------------------------------------------•-•-----------------_------------ -------------------------------------- ------------------------------------------------------•--•--------•-------------------------------------------------------------------------------------------------•-------•----------------- ------------------------------ ------------------------------------------------ _ FINAL INSPECTION BY:........... --- -or'---------- Date-------------- J . . r �. I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ho:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California K5 9 REVISED 8-59 3M 3-'63 F.P.CD. f