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, t. -FOR OFFICE USE: .,.• --------------------------------------- ----------------- APPLICATION FOR SANITATION PERMIT Permit No. ., ,5�—SZ ------------- ---------------------------- (Complete in Duplicate) -----.--- This Permit Expires 1 Year From Date Issued d � Date Issued --- - ___w 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, S49, 120 {c3 4=.a JOB ADDRESS AND LOCATION:_ � _.Y..i � _ ------------ ------------- --------------------------------- ----=-----------------•--------- - ------ ------ Phone---------------=Ow Name- w -_ -------------- `'- '. ---------------------- •----------------------------------------------------------.-------------- Contractor's Name._.-A__________ a Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ } Number of living units: /----- Number of bedrooms ___X Number of baths _____ Lot size ------ _ ----------------_______ 1 Water Supply: Public system ❑ Community system ❑ Private IM Depth"to Water Table 2-r- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam❑ Clay LoamZ Clay ❑ Adobe ❑ Hardpan4] Previous Application Made: (if yes,"date- --------- No [� New Construction: Yes 4� No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: { " (No septictankror cesspool permitted if public sewer is available within 200 feet.) r * 4 Septic Tank: Distance from nearest well ��4�__.---Distance,frorrfoundation___/.0---------. Materiai._ �------------------------ y No. of compartments----- ----------------Size_* _ `_ _ -------Liquid depth----- Capacity.-eF0 -------- ,� p� i pispasal Field: Distance from nearest well .......Distance from foundation.__�P......_---Distance to nearest lot line____s��.�-_._____ Number of lines________/__-_____�I____.._._._ Length of�each line__:__ -------------Width of trench.__i€ ----�______ m ------------ yp - -_ Depth of filter material_____. _"___-._Total length I. '__:____:____,_--_--___-__ T e.of filter, materia_ . Seepage Pit: Distance to nearest we l_/ 'Distance- ing _Size:'Dia material3� f--------_Depth_.,`.L.�-____--..___.____--_- Cesspool: Distance from nearest well________________Distance from foundation_______-_---______..Lining material__.__.__-.-____-_-_----.__--_________ q ❑ Size: Diameter------ -- --- - - -----Depth-------------------------------------------- --------Liquid Capacity- --------------------------gals. Privy: _ Distance from nearest well___----------------------------------------------Distance from earest building------------------_--________..__..____--- ❑ Distance to nearest lot line----------------------------------------------- -•--------------------- -----------------------------------------------•---------------------- Remodeling and/or repairing (describe):--------- -------------------------------------------- -------------------------y•----------•--------------------------------------------------------`. rn -------- --------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----•------------------------- - fi 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 r gulations of the Joaquin Local Health District. ISignedf Ems-. % 9 ) --- tet`- _ - ------------------ ----------------------(Owner and/or Contractor) ' By: `-r--1001 - _ _, --- {Title) _ (Plot plan, showing size.oft, location of system in relation to wells, buildings, etc., can be placed on reverse side). �y� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .G ��` i ---------------- DATE---L- REVIEWEDBY---------------------------------------------- - ---------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE-------------------------------- ------------- -------------- Alterations and/or recommendations--------------------------------------- ---------------------------------------------------- --------------------------------------------------- ' I ------------------------------------,____-__..__----__--._________________.-_._.-__._-_--_.-_.-._.__._______--.__________________-______________---__.___--._-.-__--_____._______-_---_____.___-_.___---___-____________---___- -------------------------------------------------______________________________________________________________.------_-_------._-_______.--_-__.__..._______._..__-____._________-____-____...____.__----_.--_...___--.___-__ ------------------ ___________________________________,-------_-----._-_._-._-._-_-_-._______._...._____._.._______.___.-_______________-._..-..---._._._.._-------_-____.___._..__-..__ FINAL INSPECTION BY:_.1: <r<l `------------- -------- Date-- -`C � SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street ' Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED B-59 3M 3-'63 F,RCD.