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FOR OFFICE USE: -------- = ---- ----------------------------- 1: ------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._ -_(a__476 ------- -------------------------------------------------- ., (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. a This application is made in compliance with County Ordinance No. 549. X717 a l; S• Gv +'c fou v�J � //�� ;��J JOB ADDRESS AND LOCA N:-6_ �1 —_ r - � x'uer- - ------------ •-- ------ Phone-----------•--------- Owner's Name------�-,-/f-�- f-• •-�-- -----------•-- --------r--------------------------- ---------------------------------- - ------•--- Address ,lY .r�•-.• I ,,s' " -------•----------------------------- --------------------------------------- -------------..--__-_ Contractor's Name------------------------------------------------------------------------------------------------------------------•------'-------------------- Phone...--------------------.._..------ Installation will serve: Residence Ix Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel (] Other ❑ Number of living units:. __L_ Number of bedrooms __ . Number of baths _-.1._ Lot size ------ Y____/ R_____________________ ____________ Water Supply: Public system ❑ Community system ❑ Private O Depth to Water Table''--4_.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___ ____________) 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-------------------------------------- -_-_. No. of compartments---------------- --------Size------•------------- =-•-------Liquid depth-------------------------_Capacity--•------------ Disposal Fiel : Distance from nearest well---- ____Distance from foundatio-------------------- to nearest lot/line____..___..._ Number of lines---.-----I-------- -- g � w „ - -- --Length of each line----- -----�------_----.Width of trench-__-�------------------------- Type of filter material_.-�� -Depth of filter material----/-�_-----------Total length--------- __________________- eepage Pit: Distance to nearest well-_____________________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. . f , h Privy: w Distance from nearest well----------------'--------------- -------------Distance_framnearest building--------------------------- --------� Distance to nearest'lot line------------- #._._____ ------------------------- Remodeling and/or repairing (describe):__ ----- - v r 1. -•" -----------------•-••---------------------------------------------•-••------------------------------------------•--•------------------------------------------------------------------ ._.---------------------------- ----------------=------------------------------------•---=-----------•------------------------ ---------•-----------------------•------------------------------------------------------------------- . 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) By:--------------------------------------------------------------------------- -------------------------------------------------- °-----(Title)----------------------------------- --------------------------- (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---------------------------------------------------------- REVIEWED BY--------------------------------------------- -------- ------------------------------------------------ - DATE--------/ rr-- ----f . � � BUILDING PERMIT ISSUED------- --- --•-------------- --------- - ATE ---- t Alterationsand/or'recommendations:-------------- -- ---------------------------------------------------------------------------I--------•--------------••------------------•-------------------- -----------------•--------------- --------------------------•----------------------------- -------------•----------•--------------•--•------------ j k •----•----------------'-----------------------------------`•----------------------------------------------------------•------------------------------------------------------------------------------------------------------ ..-----------_-------------------------------------------•------ -- ---- ----------------••----------- --- ---------------------------------------------- .. - - - .. /__ (94:L FINAL ------------- -------------------- FINAL INSPECTION BY--- -- --------------------------------- --- •----- ---------- Date-------- --• --------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California _ , Manteca,California Tracy, California E& 9 REVISED 6.58 3M 3-'63 F.P.CC. 1