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FOR OFFICE USE: - ----------------------------------- ------------------ -- APPLICATION FOR SANITATION PERMIT Permit No. ....�C�__ --------------- ------------------- ------ ------- - (Complete in Duplicate) �C �� 6 7 ____--------_________________________._.__.____.__.._._ 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. f This application is made in compliance with County Ordinance No. 549. /; ,� JOB ADDRESS AND LOCATION----- s.�l'i!i /��-�:l-C.r',r c fart . a—W Y.-J. �� ----------------------- ------------ Owner's .r------------------ --------------------------------- ------------- Phone------------------------------------ Address --------- -------------- -- ---------------------------------------------------------------- -----------------------------------•-- Contractor's Name---------.----------- ---------------------•----------------------• --------------------------------------------------•-------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms ___k-Number of baths J___ Lot size ______Y- ___A__-�____________________________ Water Supply: Public;system ❑ Community system ❑ private M Depth to Water Table/C7___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe t Hardpan ❑ Previous Application Made: (if yes,date.-------------------) Non New Construction: Yes E3 No,U" FHA/VA: Yes ❑ No,T 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------------------------------------------------- tpo rlNo. of compartments---------------,`----------Size------•-•--------------••-------Liquid depth-------------------------Capacity--•-------- ------ Dl Fuld: Distance from nearest well.._..!k_/__Distance from founclatio _____ d_p__�_.Distance to nearest lot line___ ______-_ Number of lines_____________I-------------------Length of each line_____ __ ._ -_ Width of trench-__--_�-. -- _____-. -y; Type of filter material-JI-2-0-4C------Depth of filter material--------�_i ..__.__._Total length_ _-��__-____ Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to neares"t/io4ne__.__-________-_. ❑ Number of pits----------------------Lining material----------------------.Size: D'sameter-----------------------Depth--------------------------------- 0 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------- ❑ Saxe: Diameter--------------------------- ----------Depth-------------- --------------------------------Liquid Capacity------------------------ gals. Privy: Distance from nearest well ______________________________________--------Distance from nearest building._________________________------_____- ❑ Distance to nearest lot line--------------- - -------------------------------------------r -------------1---------------------------- --------------------------- Remodelin and/or repairi g-(describe}:_____. d___�-__1.� __l - cr1______________ E-___ � . ' ---------------- ------ ��----- --- �---��-� ------------•--•----------------------•--------------------- -- --- ----------- ------ ------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- F I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, c� `��) ( � �+�� Joaquin Local Health District. ` n d �` - -------------------------- --- ------------ Sf laws, and ru es and regu ations o the a (Sig e ) ,//l//- (Owner and/or Contractor) By----------------------------------------•------------------------------------------------------------------------------- ------------(Title)--- —------------------ - p (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---------------- ------------------------------------------ REV �- , ATE__ - '4,L-f-------------------------------- 4 fJILIDIi\IG PERMIT ISSUED = A•TE--------- ------------------------ -------------------------- B Alterations and/or recommendations------------------ -------------------------- -----------------------------------------------•-•-------.------------------•---------------------------------- sem t --------------------- ------- ------ ---------------------------------------------------------- ---------------------•-------------------------------------------•------------------------------------------------•------CJS ---------- ---------------------- ----------------------•-••---•--•---------------•---------------•----------------------------------------------------------------------•-------------------------•----..------•--------.... --------------------- -------- ---- ----------------------------- --------------------------- ------------- ------------------- L/ i=1NAL INSPECTION BY:. r - ------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Avt. 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.P.CC.