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FOR OFFICE USE: '- ��, `{ 1 .D L Permit No. ..../ ••(1 -1..1 ----- --------------------------------------------------- APPLICATION FdR SANITATION PERMIT . .y , --------- -- -------------------------------------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ___✓✓; (°1f-•220 --is: Application is hereby made to the San Joaquin Local Health District for a permit to c�a tf�uct an Install the work here- described. E s application is made in compliance with County rdinance No. 549.�'�B ADDRESS AN LOCATION-------- __-, - -G`'��i?----=------�-------- Owner's NameC�. ---------------------•------------------ Phone.............. Address------- ---• - ----------- - ------- • -------•--•--- ------ ------------------ ,------------------------•one---•----- --------------- Contractor's Name__ - -• Ph Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1____ Number of bedroom_- Number of baths _/__ Lot size Water Supply: Public system ElCommunity system [_1Private e6e;��oam er Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No �A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted ifp blit sewer is available within 200 feet.)Septic ank: Distance from nearest weil_ _0- Distance from foun tion----!_--_------Material---- _ _________________________. Y-11No. of tom artments__ ___.. Size. T_ � Liquid depth----- __�t.__Capacity___ _ OF Disposal Field: Distance from ne st well ____Distance from foundation_/-.d_______-Distance to nearest lot Number of iines ___ _..___ ____Length of each line-------0- --„---.Width of trench____ 5 __ _`�________._ ` Type of filter material_�C.� 5-Distance _Depth of filter material_____f__q-- _Total length-__--- -- ------------------- Seepage Pit: Distance to nearest well________________ 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__._____-_____.__.________________- I ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity------------------- gals. r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-.._________________---___.._______--- r ❑ Distance to nearest lot line------------------------- ------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)----------------- - •------- . ------- c ---------------------------•----------------------------------------- --- ------- ----------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ I hereby certify hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St - I sXa rules an regulatio�Sof the San Joaquin Loca Hea h District. Si ned .. -Y�_ 4 t ----- �� = -------------------(� Contractor) ( g ) ------may B -------------•---•----------------------------------------------------------5- --- ------- A-- ------(Title)---------------------------------------- -----._. ..-- ------ (Plot plan, showing size of lot, location of system in relation to wet buildings, et , ca b5e•-placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- `/`5----------- - ---------------------------------------- DATE-------------�_ -��-- -- __- _/----------------------- ---------- REVIEWEDBY - -------------------------•-------------------- DATE-------------------•-- ----------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- DA-TE-------------------- Alterationsand/or recommendations------------------------------------- ---------------------•------------------•------------ --------------------•-•--------•---------------------------------- -----------------------------------------------------•------------------------------ -------------•-------------•------------------------------------------ ---------------•---• ---•---• --------------------------- ere -------------------------- -------------------1----------------------------I------------------------------------------------------------------------------------------------------ -----J--I------- ------------------------------------------------------ FINAL INSPECTION BY----------------------• -�-' Date---- 4.7 � 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 ES 9 REVISED B-59 3M 3-•63 F.P.CQ.