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FOR OFFICE USE; tA r --------------------------------------------------------- C� ......_-------_--- ____ ____________ ___________________ APPLICATION FOR SANITATION PERMIT Permit No. _.. --1----.----L --------------------•------ ------------------------- (Complete in Duplicate) y ----------------------------- -------------------= ------ This Permit Expires 1 Year From Date Issued Date Issued .._.-_- .- --/J� 'Z - 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 w'Tn County Ordinance No. 549. r1 JOB ADDRESS AND'LOC pct,e cam, s.['t_ yy�� ATION_ • . Owner's Name.__oe/r/-. -----------•---•-------•-•--••------------ Phone.................................... r.. Address................ .p�. r- ........ •-•-.• ........... ContractorsName:. ••---------------------------------------------------------------------------- -------- -- Phone................................... Installation will serve: Residence Apartment House ❑ Co.mrmercial ❑„ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1...... Number of bedrooms -__�_--.`Numbec,of baths /---- Lot size -__ ................... Water Supply: Public system q Community system ❑ Private ❑ ADepth to Water Table ........ ft. 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam`[A 1 Clay Loam E] Clay [I Adobe[j Hardpan C _., -- r Previous Application Made: (if yes date____________________1 No fg New Construction: Yes ® No FHA/VA: Yes Q No ❑ �— TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or ,cesspool permitted if public sewer is available within-200 feet.) (�s p 1.Q.. Material_ .........`............ Se tic ,Tank: Distance from.nearest well__,2_!h?/____Distance from foundation No. of compartments..A--------------------Size..-F-r-,;r7.--,�Liquid depth-__�-----------------Capacityl........_.._ � 1 Disposal Field: Distance from nearest well,9- '._..._.Distance from foundat o.1/A___....._._.Distance to nearest lot line........... Number of lines_________ __________"-._.___ Length of each line.f`�kO------------------Width of trent ..Zq______________ Type of filter materia rB Depth of filter 14erial-1-At ________-Total length._ __ '........................ Seepage Pit: Distance to nearest we I______-----------------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--------------------------------------------------------------•---..-------••-----------------------•---"-----•------••-------------------- Remodeling and/or epairing (describe) ` "- t(lGU . ` a l - -------------------------------------•-•----------------- ------ 1... tlr --------------------------------- .......------------------------------------------------------------------------------------------------------------------------------------------------------.------ 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)-- �'�'" (Owner and/or Contractor) -=---------.-----------------•'-----....-........-------- --------------------------------------------------------(rifle)-----------------------------•-------------- -------------------- t (Plot plan, showing size of.lot, location of system in 'relation to wells; buildings, etc., can be placed on reverse side). F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------......... ..................... DATE---6 "s?'G.., '------------.............. REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---------------------- --. ---------------- BUILDINGPERMIT ISSUED--------------...................._..........................--------------------------------------- DATE------------------------------------------------------------- l Alterations and/or recommendations:-----------------------------------------------------------------------------------------------------------------------•----- ----------- ....__.... --------------------------------------------- ----------------------------------------------------------------------------------------------------.......----------------•---•---------.-----------• -- •-----------------=- • �Ef FINAL INSPECTION BY:--- sI1/-------------------- Date------- _ 1/_�------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED 6.59 Ptd 5-6I AILAS d rrta -