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T FOR OFFICE USE: ---------------------- ------ Permit Na. ._f. --�. -------------------------- APPLICATION FOR SANITATION PERMIT 3/ ----- ---------------------- ---- (Complete in Duplicated Date Issued ....... ----------------------------- -__ ---- __. This Permit Expires 1 Year From Date Issued d in all t work herein described. Application is hereby made to the San Joaquin Local Health District for a permit to construct an This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.----- -- _/ � -�' � Owner's Name__ ---------------•--------------------- phone --------------- - _ ._ ••----- Address..--------•-• � . ------- •- ---- Contractor's Name.._-- + s_ Phone----------------------------------- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ..r____ Number of bedrooms ---3__ Number of baths 3.___ Lot size ------&CA --t..------•-------------------- Water Supply: Public system ❑ Community system ❑ Private jq Depth to Water Table lop- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam& Clay Loam A Clay ❑ Adobe ❑ Hardpan Previous Application Made: {If yes,date____________________} Now New Construction: Yes No ❑ FHA/VA: Yes ❑ No [ _,j, TYPE OF INSTALLATION AND SPECIFICATIONS: i CL (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sa-ptic Tank: Distance from nearest well__Sd.____..Distanc2 from foundation____./V.'..___.Material__ ----Size. ,`it.�' r _Liquid de th------Y---------------Capacity--:1r�.�-•--- �] No. of compartments ----.---.- - ? G p• Disposal Field: Distance from nearest well-.r -_.....Distance from foundation..b-___------Distance to nearest lot tine... ..•._.. _ Number of lines----- '--- ----- ------------ ength of-each line------tfQ---------.-------Width of trench...�1R.-------•------------•-- Type of filter material _Depth of filter material_-_-_1 -----------Total length__,�I - •--. �'- ( ----- Seepage Pit: Distance to nearest wel ____-f 0"�!'.___Distance from oundation__./_ �____....Distance to nearest lot line- '�'-.--.- Number of pits-----X---__-------Lining material4 --__._.Size: Diameter---,-,,�i_!--______-Depth-A.4__�------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material..-_________-______..._.____•-----__. ❑ Size- Diameter--------------------------------------Depth-------------------------------- -------------------Liquid Capacity-----------------------....gals. Privy: Distance from nearest well----------------------------------------- _______Distance from nearest building_____-_______-_.._______-_-_--___________- .r- ❑ Distance to nearest lot line------------------------------------------------ .---- ---------•----------------------------•-------------------------------------------- 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 of the San Joaquin Local Health District. 4- - 1.-' {Owner and/or Contractor( ---- 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 t APPLICATION ACCEPTED BY- -------------- ---------------- DATE------ �, 0 ' ------------------------ REVIEWEDBY---------------------------•---------- --------------------------- ------------------------------------------ DATE------------------_-----------------------•••------------ BUILDINGPERMIT ISSUED----------------------- ---•------------------------ ---------- ------ DATE------------------------------------------------------------- Alterations and/or recommendations:----------------------- ------ ---------------------•...................----------------------------------....I------- -•-•............. •--------------------- ---------------------------------------------- ------------------------------------•------------------.--------------------- --•----------------------------------------------------------------•--------------------------------------------------------------------------------. ---------- --------••------------------- --•------------------------------------------------------------------I-----------------...-----------------------------------.-- -- - ----------- ___1 /� FINAL INSPECTION BY: �._ ... .'r'�� Date_ --77---- ----_ Z SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strout 300 west Oak Street 124 Sycamore Strout 205 West 9th Street Stockton,California Lodi,California Monte d `California ` Tracy,California E8 50 REVISED B•59 2M 6-61 AILAB � .,�—�.�(�er`i' � +f+iL��' •��' `