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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------------------------------- ---- -- --- --------- (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 in all the work herein described. This application is made in compliance with County Ordinance No. 549. 7W� !Z 174,3& N• /416,,c w r4 IF n G JOB ADDRESS AN ATION _- C :r- ------------- l �-�-a%-Cs> Owner's Nam -- ---� - �7-----•--• ----- - Phone r1 d— ------------------------------------ Owner's Nam ----- --- ------ ---- ---------------------------------- ---•- P / Contractor's Name---------------- ---------- - -- T --,------ ------- Installation ----- ' Phone.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Traililerr Court ❑ Motel [3Other ❑ Number of living units: __/_- Number of bedrooms __y7Number of baths 57_? Lot size --__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table�Clly t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ 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.) Septic Tank: Distance from nearest well------_--------Distance from foundation-------------------Material -.------__....._-._-----_-_-__-___.------------ ❑. No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dispas Field: Distance from nearest well..S !....Distance from foundation---- -------------Distance to nearest lot Iline�----------- Number of lines--------- Length of each line_____ ........ Width of trench.__.? __r____________________ Type of filter material- of finer materiaf___..¢__1�______-----Total length-------V___a--------------------_--__. [� Seepa it: Distance to nearest ell ----- _ / �_.___..r__.Distance�to nearest lot Iire�_ ` P ____Distance fr ,foundation____ __ X11'' -_-.-_ Number of pits-___ } -----------Lining material----- (f -,.---Size: Diameter.-.-- 3-------Depth-......-----_-----------------_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------------- ❑ Size: Diameter------------------------------ ------ De,ofh-------------------------------------------------.--Liquid Capacity-. .------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 11 Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe : ---- -- ----- ----------------------------------------------------------------------------------------------------------------------- T -------------------------------------------------•------------•------- - --------------------"----------------------------- ------------------------------------------------------------------------------------------------ -----------------------------------•--------- -------------------•-----------------------------------------------------------------------------------•----------------------------------- ----------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- I hereby certify t t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, a d rules and re attons of San Joaquin Local Health District. {Signed} ----- and/or Contractor) --------- gY. :....... --- ------------------- (Title)----------------------- --------------- __ (Plot plan, showing size of lot, location of system in re n to wells uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE BY___ I -- - - --------------- --------------------------------- DATE------f-�---��---�-`-�---------------------- REVIEWEDBY- f'`J- —------•--- ------------ --------- ---------------1 .---------------------------- DATE d" - ------- BUILDING --`f BUILDINGPERMIT ISSUED-----------------------------------------=`--------------------------------------------------------- DATE--------- ------------------------ ------------------------ Alterations and/or recommendations:---------- ------ --•.... -------------------------------------- '-----•------•-----------------------•---------------------- w ,.,-- - - j f -----------------_-----------------------------------_-------____---------------------__i..._---_---.._-_-_-.-_-..__________________.__.------------------------------ I -----------------------------•- -- ----- --------�--------- ----------- ------.-1------——---_-------- ---- ----------- --------- ---------------------- . ._ FINAL 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 E$ 9 REVISED B-59 3M 3-'63 F.P.DD.