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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No_ _____ ---------------------------------------------------- ---- Date Issued ----- -�/ -------------------------------------------------------- (Complete in Duplicate) 7 ----------------------------_.---..- ----------- -- - This Permit Expires 1 Year From Date Issued .••./�• �. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worfc'herein described. This application is made in compliance with County Ordinance No. 549. 007 - � � -1 ---------c --- ------ ------JOB ADDRESS AND LOCATIONY1 �/ �U= Owner's Name---- 1 Phone - ------------------ ----------------------- -•-- Address °ICI . -- --------------------------------- Contractor's Name--•-- -----•--- r ---- --------•---•------------------------------- Phone----..----------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _t.---- Number of bedrooms 4--- Number f baths - Lot size --- - -------- _g,�------------------------- Water Supply: Public system C] Community system ElPrivate 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----------.---------) 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--------- -•----------- Disposal Field: Distance from nearest well--------------_-Distance from foundation-----__-------.---.Distance to nearest lot line------------_---- � E ] Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ Type ------------- ---.--Type of filter material-------------------------Depth of filter material---------_,-----------Total length------------------------------------------ !I / r r 6- , N Seep e Pit: r Distance to nearest well_- ----Distance from foundation-----ZA--------Distance to nearest lot line----------------- " } Number of pits------.I---------_-Lining material.---_---.Size: Diameter.--_-::�- . ------Depth-- $--------------------- ^^ l71 Cesspool: Distance from nearest well--------------._-Distance from foundation--------------..----Lining material------------------------------------- Size: --.----------.-----.--------_Size: Diameter-------------- .- ----------Depth----------------------------- ---------------------Liquid Capacity-------------_,- _,------gals. Privy: .Distance from nearest well------------- ------------------------------------Distance from nearest building------------_--_-----__--_-------------. ❑ Distance to nearest, lot line-----------------------' ----------------------------------------------------------------------------------•---------------------- Remodeling and/or repairing {describe):-- '----------- ^- ---------------------------•--- 1 -------- --------------------------------------------- ------------------•------------------------ ------------------------------ ------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------- 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. (Signed)---------- -- s and/or Contractor] By---------------- -------- ------------------------ rifle (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 ACCEPTED BY--- - -- --- --------------------------------------------------- DATE----- --------------------------- REVIEWEDBY-------------------------------------------`--------------------- ---------------------------- ---------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------ ------------------------•----- Alterationsand/or recommendations------------------- ----------------- ---------------------------------------------------------•-----•-----------------------•-------------------------------- -------•-------------------------•-------------------------------------------------------------------------- -------------------------------------------------------------------------------------------•--------------------- ------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- --------------------•------------------------------- FINAL INSPECTION BY:--- �!��G �/�' - - iEe ----- Date.... -��^- J SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,Callforala Lodi,California Manteca,California Tracy, California ES 9 REVISED B-59 3M 3-'63 F.P.CO.