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FOR OFFICE USE: �� d 3 b--------- - ---------- APPLICATION FOR-SANITATION PERMIT Perpit No -------- - -------------------------- ---- ----fY/ -6-1---"-- --- ------ (Complete-in Duplicate) Date Issued This Permit Expires 1 Year From 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. 11 9a�9 ------ -------------- JOB ADDRESS AND CATI N__________ _____ Owner's Name f --------------------------- Phone ------ ------------------- -- Address--•-------------- ---•-- ----- .------•••- -- = �� 1 Contractor's Name 4 -------------- Phone_' �� 7f Installation will serve: Residence [Apartment House ❑ Commercial ❑ -Trailer Court [] Motel ❑ Other ❑ Number-of living units: _/-_ "__ -Number of bedrooms Number of baths.-_-/- Lot size ----- _-6_-Q_`XZf�.a-------------------- I Water Supply: Public system [�ommunify system ❑ Private ❑ Depth to Water Table;y�- ft Character of soil to a depth of 3 feet- Sand [:] Gravel E] Sandy Loam [❑ Clay Loam E] Clay ❑ Adobe N" Hardpan ❑ t Previous Application Made: (It,yes,dote............. 1 No New Construction: Yes ❑ No ©---F_HA/VA: Yes ❑ No ❑ ; TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool per'mifted if public sewer is available within 200 feet.) Sc tic k: Distance from nearest well_____________ __Distance from foundation--------------------Material -----._.___------._--.___________---------- No. of compartments----------_- -.----Size-------------=------ -- ----- Liquid depth--- ---- ------- ---------Capacity----------------------- 'Isp ie Distance from nearest well---------- ----"-Distance from foundation_____--a.---------Distance to nearest lot line_____--_-_______- Number;of line's:_.---------------------------------Length of each line------------------------------Width oftrench--------------------------------.-- G Type of filter material---- _-__--_--.-.--_Depth of filter material------------------- ---Total length----_______________________________---.-- Seepage P t: Distance to nearest well e K-_Distance m fo ndation____ �?__/...Distanc,� to nearest lot line r_-J____._ • Number of pits.._ __ --------_-Lining material- G � Size:'Diameter_��_._".-._ p Cesspool: Distance from nearest well ---- ----------Distance from foundation ----------------- Lining material _____________________________________ ❑ Size: Diameter- -- -------------- ------------- --Depth-------------- --- ---------------------------------Liquid Capacity- --------------------------gals. 1 Privy: Distance from nearest well--------------"-----------------------------------Distance from nearest building_______"-___._-___-_----____---_-- i ❑ Distance to nearest lot line ---------------- I Remodelingand/or repairing (describe-- ------- ------- ---- ------------ -----------------•------------------ ---------------------------------------------------------------------------- - ------------------------------------- -- ------ ----------I-------------------------I-------------------------- ---------------•---•----------------------------------------------- ------------------- ---- I hereby certify that l have,prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Maws, nd rules an egula ' ns of the San Joaqu Local Health District. it _ - ------------ --- Ow er and/ tract or ------------------------ 7- (Signed) or Con ( I,. --- -(Title) $y:-------------------------------- Y (Plot plan, showing size of lot, location of system in relation to wells, buildi s, etc., can be pla7edan reverse side). i FOR DEPARTMENT USE ONLY - 677 APPLICATION ACCEPTED BY------ )- ` --- -- ---��----------------------- ------------------------------------- DATE. f - I, REVIEWED BY----------------------------------- ---- ----------- ----------=--- --- DATE---------------------------------------------•-•------- BUILDING PERMIT ISSUED------------------- - -j ------ - ----- RATE---- -------- ------ - ---------- - •------- Alterations and/or recommendations:----t f�' �)=~.t°Q" ------------ - - — - -- -------- -- ------------- ----- ---------------------------- ------------------------- "V' �•�- ° ------ !• -•-__-•---_•--.......•-•-•...... .......... .........................--------------------------------- - i .. I n - E. FINAL INSPECTION:BY=� --- ---- --- i - -- " - -------- - =--== Date--------- "-��-�.',�.-�"-- ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 174 Sycamore Street 205 West 91h Street Stockton,California Lodi. California Manteca,California Tracy,California I}} E.H.9 2M 1-67 Vanguard Press r'