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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _J�-l.. ------------------------------------------------------- gg9 --------------------------------------------------------- -------------------------------------------------------- (Complete in Duplicate) / la� --------------- --- This Permit Ex ires 1 Year From Date Issued Date Issued ____ -_ ______-- Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. p l-7/ JOS ADDRESS AND . OCATION r _ --- - .................. - - -! _ '--a----------------- Owner's Na a----- - ------- - ------------------------ Phone----------------------------------- r Address ---s�� •-- ..... .-•-----•----.. .... - --------------------•-----..._---..._-----------•------•------------ Contractor's Name ---.I-- ----- - - ---------------------•-- -•-----. -------------------- Phone----------------------------------- Installation will serve: Residence l-3 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms.. Number f baths __ Lot size ___________________________ ----____--__-_______..__-_ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date....................1 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.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------.-----------.----..-._.-___---____________- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity----------------------- o pispos field: Distance from nearest well,...... f Distance from .10 ----- to nearest lot line____��__.___..... Number of lines---------- _.___--_Length of each line--------,-(---- -----------.Width of trench.--r�-------------------------- Type of filter material-_-rU? --------Depth of filter material----I --------Total 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--------------------- ---------------------- ------------------------------------------------------------------------ ---- ---------------- 1 Remodeling and/or repairing (describe)------- - -------------------- ----------------------------------------------------•-----•-- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ I hereby cer+if that ! have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a and rules and regulations of the San Joaquin Local Health District. (Signed)----- ------- - --------- ----- ---- -------- - ------ el and/or Contractor) By ----------- --- (Title) - ... .. (Plot plan, s owing size of lot, location of sys+em in relation to well , buildings, etc., can be placed on reverse side]. ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ..__ _________________ DATE__ REVIEWEDBY--------------------- -- --------------- ------------------------------------------ ----------------------------- DATE--- -------- ----------------------------------------------- BUILDING PERMIT ISSUED--- ----_---•--==--------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations------------------- ----------------•-------------------------------------------•---•-----------•--------------•- --------.------•------------------------------ -•---=----------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------•---------------------------•---- --------------------------------• ----------------------------------------- ----------------------------------- -------------------------------------------------- ----------------------------------------------------- ------- -----------------------------------------------•--- ---------------------------------------- ------------------------------------------------------------------•---- ---------.--------------.------------------------.----------------------------------------------------- FINAL INSPECTION BY - -- -- ------ -- .--------------- Date__�._f�_. � � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED S-59 3M 3-'63 F.P.CC.