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FOR OFFICE USE: ----- ��_1. G ---- _ APPLICATION FOR SANITATION PERMIT Permit No. ....,__ . /:..... - - ----- ------_ _----------------------- (Complete in Duplicate) �3� -- Date.lssued,. This Permit Expires 1 Year From Date Issued ' ------------------------------------. II Application is hereby made-to the San Joaquin-Local Health District for a permit to construct and install th work herein desert ed. This.ap lication is made in compliance With Count Ordinance No. 549. �r 42- �3� " 3 N .� • � ' � oGy PiJOB ADDRESS AND LOCBi ------- -------------- Phone.--------------- ------------- r s Name---------- 01 Owne -------`------------------- AddressLis'�T "7 - ------------------------ Phone ---------------------- ------�s� - __ ? Contractor's Name------ ''{ Phone. Number of livin units: __ - -- Number of bedrooms -- Number of baths_3__ Lot.size�_______.1 -� .r ❑ 5 ~ Installation will serve: Residence Apartment House Commercial Trailer Court Motel Other p ❑ Nug l ----------------- Water Supply: Public system. ❑ Community system ❑ Private`T\Depth to Water Table __ �tt. C;�\ Character of soil to a depth of 3 feet: Sand ❑ Gravel [ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ -C\ Previous Application Made: (If yes,date..--------- No 0, New Construction: Yes No ❑ FHA/VA: Yes - No E] TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest well____�d�__.-Dist e from foundation____.) Mater' I_ r_U- -'�----------- Liquid depth---------- `7� Capauty �' S �-- � � - No. of compartments...-- -----=---- ---Size-----•--------------- (( �9 f U�-__;^_Distance to nearest lot line `s_..________ Disposal Field: Distance from near well----/f2_Q._Distance from foundation----..�- . Number of lines-- - ------.- _-Length of each line___ _- ___.___ d�__._-.Width of trench..__r� -- �0 Type of filter materialcl./_� ? -Depth of filter material____Z,.-.-�_.____.Total length_____l_ __________________________ Seepage Pit: Distance to nearest well______________________Distance from foundation___-_______________.Distance to nearest lot line_________--._____ ❑ _ Number of pits-----------------------Lining material-----------------------Size: Diameter-------- ---------------Depth------ L Cesspool: Distance from nearest well----------------_Distance from foundation--------------------Lining material---.---.. ___._______.__.----_______. IS 0 ❑ Size: Diameter------------------------------ ------Depth------------------------------ ---------------------Liquid Capacity------------------------ Priv Distance YfromTnearest welh'" __. -� --- Distance from nearest budding ,,____________ ______ ❑ Distance to nearest lot line------------- -- -------- ------------------------------- --------------- ---------- o� Remodeling and/or repairing (describe)------------------------ -------------------------------=----------------------- ----------------------------- - --•------------------- ----------------------I-------------------------------------- -----•--------- ---------------------------------------------------------------------------------- ------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- - - C - ---- -- --- -- - - ------- I hereby certify that I have prepared #his 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) iii ----------(�or Contractor) -------------By:------------------------- - ----------------------------------(Title) ----=--- ---.. . ------- ---- -- (Plot plan, showing size oocation of sys in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLIREVIEWED BY DATES _.�.. -y�J -------------- CATION ACCEPTED BY------------------ ---------- ------- -------------- ------------- -•--- ---- ------------ DATE------------------ - ------- -------------- BUILDINGPERMIT ISSUED------------------------- -------------------- �_ � ------._ DATE----------------------. .......I---- ---------------- -- Alterations and/or recommendations:------- ----------- • ----------------------------------------•----•----------- :-- ._--------------------- l --------------------------- ------------------------------------ ------------------------------------- ------------------------------------------------------------------ --------------------------- ----------•---------------------------I�---------------------- _______________-------_--------_---_______-----------.-----------------------------------------.--_ --------------------- ----- --------- r -I FINAL INSPECTION BY----- - --- ---- ----- --------------�-,-------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton AVG. 300-West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California Es 9 REVISED 8-59 31A 3-'63 F.P=-