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FOR OFFICE USE: cf , -------------------------------------------------------- . APPLICATION FOR SANITATION PERMIT Permit No. ._ - -- �._ ---------------------- --------------------------------- (Complete in Duplicate) Date Issued ------------------------------------------- This Permit Expires 'I 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 O Bina e No. 549. �9 JOB ADDRESS A D LOCATIO ...._.- ._._.. Owner's Name 61CII� � �--------- ------------------------- Phone------------••---------- Address. r —� --- - -•--------------------•---•-----------•-------•----... ------------------------ Contractor's Name---- --------•---- Phone - ---------------------------------------------------------------------- -- Installation will serve: Residence �partment House ❑ Commercial p Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___(___ umber of bedrooms ---In—Number of baths ----t_ Lot size :___ tS��_____ _'_�_________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table SA?ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sgddy Loam ❑ Clay Loam ❑ lay ❑ 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.) f �/� �� Septi nk: Distance from nearest well..............__-Distance from foundatior>�f)�3----_______.-.Material___ __ ----- -- No. of compartments______2.�-___________Size-------��__j_X_�Liquid depth___�_-_______________Capacity_____,r�Up�_ Disposal Field: Distance from nearest well----- '_____Distance from foundation--/a_____________Distance to nearest lot line.`.-...____. A dumber of lines------ Length of each line 1�''_4'__f_________________Width of trench___-�_`"------------------ r 10 Type of filter material 10_L.!�______Depth of filter material_r_&---------------Total length____--�?o______________________..__-- ..� ' Seepage at: Distance to nearest well_________-------------Distan��om foundatson__4Q__----------Distance to nearest lot line__S.__.___-------- s Number of pits----[----------------Lining ...Size. Diameter---__ Depth.-_-.2s� ------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------C ❑ Size: Diameter--------------------------------- ----Depth---------------------- ---------------------------Liquid Capacity- -----------------•-----gals. Privy: Distance from nearest well__________________________ ______________________Distance from nearest building-.--------._____________________._._.._._. t ❑ Distance to nearest lot line------ -- ------------------------------------------------------------------------------------------------------------------------------------ . 4 Remodeling and/or repairing (describe):---------------------------------------------------------- ------------------------------------------------------------•-------------------------------- -------- ------------------------------------------------------------------•-••----------------------------------------------•------------•----------------•-----------------------=---------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------- 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 the an Joaquin Local Health District. (Signed) ___________________Owner and/or Contractor By:.............................-------------------- --- -------------- -�---------------------------------- � %(Title)------------------------ ----._...-------------- (Plot plan, showing size of.lot, loca s em in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------•------- --------------------------------- -----4rf-5--------------------------------- DATE----------- 3 ----------------- REVIEWEDBY------------------------------------------------------------------ ------ -- ---------------------------------------- ------ DATE------------------ --------------------------------- BUILDING PERMIT ISSUED-------------------- DATE -- ---------------- ------------------------------:__ :: --------- ____._Alterations and/or recommendations:_- 1_ J _ --- ------------------------------------ -------------------------------------------- ------ ------------------- ---------------------------------------- -------------------------------- ------------------------------------ 7 6FINAL INSPECTION BY:---��------------------- ---------------------------- Date---------- -------- .............. -- ------------------------------ SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California { E5 9 REVISED 9-59 3M 3-'63 F.P.CO.