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FOR OFFICE USE: } -----------------I--------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----- --- --------------------------------------------- (Complete in Duplicate) ---------------- This Permit Expires i 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. JOB ADDRES A D LOC AT ON_- _- -.---- ------ - ------------------- - ------------------- - -------------------------------------- Owner's Name___ -- Phone--------------------------------- _ -- Address ------------- rll-. Contractor's Name---- - ------ ------ - ----- -- ---- --------------------------------------------------------- Phone-------------------------------- Installation will serve: Residence [ Apartment House ElCommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._l--- Number of bedrooms _� Number�f baths _L____ Lot size ___�__ 1--�' ra.�s.__�________________ Water Supply: Public system El Community system El Private [�`I 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----------__-------_I 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------------------------------------------------- F1 No. of compartments--------------------------Size--------------------------------Liquid depth----------- --------------Capacity-------------------- Disposal Field: Distance from nearest well_________________Distance from foundation-___--_-____..__.Distance to nearest lot line------------.. . 1A ❑ Number of lines-----------------------------------Length of each line---------------------------._-Width of trench------------------------------------ Type of filter material----------------------_---Depth of filter material-----------------------Total length-------------------_---------------------- i z � i Seeps e Pit: Distance to nearest welL _�_ __ b_C-----___Distance from foundation-----�L2_______.Distance to nearest lot l-sne---_____--------- Number of pits____..._/-----------Lining material____-IZ__:-------Size: Diameter_______�_3_---.___Depth__2_.C------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____._._______________.__._________- Z ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____._._____,_-_____-__.---------------- ❑ Distance to nearest lot Iine--------------------------------------------------------------------------------------------------------------------- ---- ---- Remodeling --Remodeling and/or repairing (describe)---- ---------------- ----- ----------------•--------------------------------------•-----------------------------------------------------------•-------- ift --------------------------------------•----------------------- --Qc.�Q( -t � r ------------------------ ------------------------------------•-------------------------------------------------------------------------------------------------------------------•----•---- -----------------------------9 1 hereby certify that I.have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, aws, and rules and regulations of the San Joaquin Local Health District. y (signed) - - -------- - ----- ----------------' -------------------------- (E)wi 'r and/or Contractor) BY '•---•-• ---------------------------------•---------------- -----(Title)--------------------------------------- -- (Plot plan, showing size of lot, location of system n relation to wells, buildings, etc., can be placed'on reverse side). r FOR DEPARTMENT USE ONLY `�f _ ._ '� --- APPLICATION ACCEPTED BY �-� � - DATE_ ----------l--- ------------ ---------------- REVIEWEDBY--------- ----------------------------------- --------------------- ----------I------- -------------------------------------- DATE BUILDINGPERMIt,ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------------------------------------•-•-•----•---•-------•----------------------------------••---------------•---•-------------•------------- -------------------------------•-- ---------- ----- --------------------------------- -•-------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- -•----------------------- - ------------------------------------------------------------------------------------•------------------------------------------------------ FINAL INSPECTION BY:--ZN ------ _ _- - bate_..,�_T1�_'.�6 ---------------------------------- 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 ES 9 REVISED 6-59 3M 3-'63 F.R.CC.