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FOR OFFICE USE: vo.5 yell p i APPLICATION FOR SANITATION PERMIT Permit No. �.�!.�..�...... -------------------------- --------- ------ ------ (Complete in Duplicate) .__�.. ---______..________---._._____--_.-.-__.__ 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 ounty OrdinAwcp No. 549. JOB ADDRESS AND LOCATION -------- -j- = - = •-----a ... -------------- /--- ...........................---------------------- Owner's Name "= =F- -- -��---- - --- ---•--- - ------------------------ --••-••--- Phone.............. •-------•------------ Address---------------------- x....... - ---�-�-�-`--' -- �---�---------------1-------------= --------------------------------•-----------•----------•--------------.. o- Contractor's Name---------------------------- �- ---------------------------------------------------------{-------------------------- Phone ,r� -=_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ / Number of living units: ._�___ Number of bedrooms ---1___ Number of baths __!._.. Lot size _____ ---------------------------- Water Supply: Public system ❑ Community system E]"' Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 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 s war is available within 200 feet.) Septic Tank: Distance from nearest well..d' Dist ��.#pm f ugylat'ons>1 _......_.Material__�'u'-- 7`�`4-F y' No. of compartments_-_-___.___�_.__-_/-Size., _ ._. __G,lr _e✓Cnquid depth__..__ __J�_______._CapacitY...,f�!':-"%--___ Dispos I Field: Distance from nearest well___o/.MAistance from foundation---�:-�f._.....__.Distance to nearest lot line_=`t......___. \\ 7 Number of lines---------------4- _�__.,Length of each - _` /1/idth of trench__ _ Type of filter material..._ __1_[4 Depth of filter material___f ____-____----Total length___-__-- _____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 171 Number _.---_-___--___-❑ Number of pits______________________Lining material-------------.---------Size: Diameter-----------------.-----Depth_..._..___.______...__.______..__ `r( Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material----------------_---____.__-___--_-_- ❑ Size: Diameter----•- -------------------------Depth-------------------------------------- -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building-________________________________________ C, ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------ \� --------------------------------------------------------------------------•-------------------------------.------------------.--•---.---------------------•------------ --------------- --------•-------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - - --------------------------------------•----•------•------------------------------------------------------•-----------------------------------------------------------------•---------- --- 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 hegulations of the San Jo inLoyal Health District. o (Signed) � C (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 APPLICATIONACCEPTED BY------------------------------------------------------------------------------------------------- DATE---------.---------------- ----------•---------------------- REVIEWEDBY-------------------------------------------------------------------- -------------------------------------------------------- DATE.---------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------- --------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------•-•--•-----•-------------•-----•----•-------•------------•--....... - -------------------------------------------------------- -------------------------------------------------•----------•---------•---------------------------- ---------------------------------- ----------------------------------- ----- ------------------------ ---------------- -------------------------- ----------- A4 FINAL INSPECTION BY:. fF- Date------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hozolton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3-'63 F.P.CD.