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FOR OFFICE USE: --------------------I---------------- -- -------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 32 --- ----- ----------------- ----------- 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. This application is made in compliance with County Ordinance No. 549. 1-6 o JOB ADDRESS AND C1ATIO Z------- _' I -- "1 ��!' ----- ... Phone. Owners Name -------------------------------- - ----------------------------------------------- Address I .. Address. � z. -------------- ---- --------------- ------------------- - A = a Contractor's Name-------- ----- �'� �¢ Phone.. ... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I___ Number of bedrooms 11 Number o aths -- _. Lot size ---- 10"_11___e__.::P_____xk9-------- ------ Wafer Supply: Public system [I Community system El Private Depth to Water Table.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay LoamClay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 7 Septic Tank: Distance from nearest well_________________Distance from foundation----.--------------Material-------------------------.-----_-_--._..________- ❑ No. of compartments---------- ---------------Size--------------------------------Liquid dep osath----------------- --------Capacity------------------- Dispfield: Distance from nearest well___. ..._Distance from foundation___..--- 0-----Distance to nearest lot line___._--_.... Number of lines----------- I----- Length of each line----___ E 9 Width of trench. .- Typ of filter materials-_ Depth of filter material-_______- ______Total length___-____f_ C-----------_____________ 'Seepage Pit: Distance to nearest well-____________________Distance from foundation-______--_..______..Distance to nearest lot line-------._---_____ �r ❑ Number of pits,---_-;- ------Lining material---------- -----------Size: Diameter-----------------------Depth---_----------------------------- Cesspool: Distance from nearest well;______.-,a_--.-_Distance from foundation--------------------Lining material------------------------------------- El - Size: Diameter`_--------------- ------ -.-----Depth--------------------- ------------- - -------------Liquid Capacity- -------------------------gals. ' Privy: Distance from nearest well----------•--- -- ---------------------------Distance from nearest building-------------------------------------- 95 ❑ Distance to nearest lot line.___.,---------- _________________________________ Q� Remodelingand/or repairing..(describe);------------------------------------------------------------------------------------------------------------------------------------------------------" 6 , --------- --- -- ------------------------------------------------------------------------ ---------------------------------- --------------•------- r s---•------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta#e s, and rules d regulation of the San Joaquin Local Health District. (Siii -----------------------------------�nd/or Contractor) gned)------------- ----------------- BY� -- - ------- (Title) - (Plot plan, showing size of lot, location of system in relation t wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ~----------------------------------------------------------------- DATE----3`?'A--t ----------------- ---------------- REVIEWEDBY--------------------------------------------- ---------------------------------------- -------- ----------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------- ----------------------------------------------------------------- ---------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------- ---------------- - -------------------------------------------------""------------- --------------•------------------------------ -------------------------------I------------------------------------------------ ----------------------------•-•-----------------------------------------------------------------------•--- -------------------------------------------------------------------------------------------------------------------------------------------- ----------- •-• ------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- --------- -------------- --------------------•--•----- -"------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:. ---- - ------------- --------- Date---- ~l'� y----------------------------------------------- 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 E5 9 REVISED 0-54 3M 3-'63 F.F.120. 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