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FOR OFFICE USE: ________ __________._._._--__;____._ APPLICAtION FOR SANITATIONQMIY Permit No. 1 � -- (Complete.in Duplicate) 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. This application is made incompliance with County Ordinance No. 549. OB ADDRESS AND LO ATION--- w__ ._ .._ / _ � ---------------------- Owner's Name----- 4G------ -- G ?rt ------- -- - --------------------------- Phone----.----------- Address----------- Contractor's Name----------- r ¢ ------ Phone---------•--------"-----" Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E� Number of living units: Number of bedrooms -------- Number o baths __ Lar size __________________ Water Supply: Public system ElCommunity system ElPrivate Depth to Water Table -------- ft, i 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 0 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) u� Septic Tank: Disfance from nearest well________________Distance from foundation--------------------Material _._-_______,___.___.___...___.______- ❑ No. of compartments. ...... -...... Size----------------=------•---- ---Liquid depth-------------- ---------- Capacity----------- ) j - ` Drepos Field: Distance from nearest well ------Drstance from foundation----/ _________Distance to nearest lot line_________________ ��; Number. of lines______________f__ * Length of each line__---__-40.0___--___--_.Width of trench.- ._�Type ofJi4er material----- --- -- -- -,__---Depth of filter material--------/-?---------Total length---- ----------------------------------- a _-:--------------- --- r Seepage Pit: Distance to nearest welt----_._,_____---- ____Distance from foundation-------------------.Distance to nearest lot line------ ❑ Number, of.phs` I -k ------,fining material Size: Diameter-----------------------Depth--------- -------------------- ---------- D . Cesspool: Distance from nearest welL`�-`_-'\_Distance from foundation,_________,. - Lining material__--____________________-_ � ate.... ,. '= �'Depth --------- -3------------------- ------Li Liquid Capacity- . gals. ❑ ��Slze .Diameter - q P Y - i' Privy: Distance from nearest well____---.___I t l,r --=--------------------------------Distance from nearest building--------------------------""""-- 1. --------- Distance to nearest lot line__________ __ - Remodeling and/or repairing (describe)------------- ------------------------ ------------------------------------------I----------- -------- -•------------ -----------------------•--•-------- -- -------------=------------------------ . -------- -------------------------------------------------•---------------•---------------•--:- --------------------------=---------------------------=------------- ---------------------•------- ------------------ I hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, rules and regulations of the San Joaquin Local Health District. (Signed) Q[ZZ Cont ) - ------ ------ -- •- -- ----- and/or o c ---- --------------------------------------(Title)--------------------------------------- (Plot plan, showing size of lo.t, location of system in relatio to wells, buildings, etc., can be placed-on,reverse,side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_/ ---z< � - DATE----�_- _ ---------------------------------- REVIEWED BY------------------------ ---- ------ DATE ------=----------- BUILDING PERMIT ISSUED '-------------------------------_ --- . t t _ _ DATE ------- �.,,� ----- r: - - Alterations and/or recommendations:.__ �" "" -_.� �ti . s --------------------- V. - -------------------------------------------•----------- - ------------------ ----------- ---------------------------------------------- -------_-"_-. ---------------------------------- ---------------------- ------- FINAL INSPECTION BY:,r --- - ,A ----- --------- - ------- Date--- --�_-7°r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hatellon Ave. 300 West Oak Street 124 Sycamore street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3`63 F.P.ra. 1