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FOR OFFICE USE: ------ ----------------------- ----- APPLICATION FOR SANITATION PERMIT Permit No. .. :�5 y.. a (Complete in Duplicate) _,_.__. ` This Permit Expires i 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 in compliance with County Ordinance No. 549. JOB ADDRESS AND LLOCATIOI�/ 751/$ "--" �`r Owner's Name---------/.� / ', - ---------- ----- •---------- -----'----------------- -------- ------ Phone------------------•--_----------- �LL - Address i ...... 19 { 1 - � ---------------- y ---- Contractor's Name-----____ _ I Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: _-_ Number of bedrooms __ __ Number of baths _/---- Lot size __ _ --_'__._____------------ t Water Supply: Public system ❑ Community system ❑ Private [Depth to Water.Table 4J-ft" Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ Adobe ❑ Hardpan Previous Application Made (If es,date..- --- -- _) No New Construction: Yes ❑ No Er FMA/VA: Yes ❑ No TYPE.-OF INSTALLATION AND SPECIFICATIONS: *=�(No sepfic fankworcesspa I-permittd f publi ewer is available within.200 feet.) Septic Tank: Distance from nearest well------------------Distance from foundation-'--.---------------Material______--_-_--.____.______.._________.__-_______. , Noof compartments-------------------- -----Size.- ----------•-------- -------Liquid ciepth---------------------.----'Capacity-------------t---------- Disposal.Field: Distance from nearest well-----------------Distance from foundation----------;-___'___.Distance to nearest lot line_____-:___.._____ 1644-f Number of lines------------------------------------Length of each line-------------------4---------Width of trench----•---------------------------•-- _Type of filter material----•-------------------Depth of filter..material-----------------------Total length--_-------- .------_-.-------_---------- �� _ .- Distance from foundation__.f- Dlstai7e to nearest lot lin See a e it: Distance to nearest well.-_ _-_. _._ _ ..� _s_______.__+ Number of pits____/_.______-Lining material_�t7 __.Size: -Diameter__.�V. __ -.Depth d�e�l_______________ ___ x essp ol: Distance from nearest well----------------- from foundation--------------------Lining material-___.___-___--.--.--------___________- ❑ #. Size: Diameter---------------------------------------Depth---------------.---_--------------_------------------Liquid sCapacity----------------------------gals. Privy:' _ Distance from nearest well-__________________________ ____________________Distance from nearest building ❑ Distance to nearest lot line------------------------------------------- ------------------------------------------------ ---- -=--------------------------------------- Remodeling and/or repairing idescribe)---------------- - f �' `-•---------------------------------- •------------------------ ---------------------------------- -----------------•------------•--------------••------------------------------- - -- --------------------- --.-------------------------------------------------------------.-------- ---------------------------------------------------------------------- ------------------------------------ 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. (Signed)-------------------------1-f& � f � -- -------- -------------------------------------------(OwTmr M/orTContractor) By' -- - -----------�(Tifle') - F (Plot plan, showing size of lot, location of system i r ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- /_ --15------.--- DATE---� -- � --------------------------- -- REVIEWEDBY--------------------------------------------- --------------------------------------------------------------------------- --- DATE---------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------}-------------------------------------- DATE---------------------------- -------------------------------- Alterations and/or recommendations---------------- ------------------------------------------------------------------------------ -----------------------------•--------------•------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------I------------------------------ ---------------------- ----------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------- ----------------------------------------- ---------------------------------------------------------------------------------------------------------------•-.---.----------------.-------.---.---------- ---------------------------------------- -------------------- �� . FINAL INSPECTION BY:_ �'_____ ________--.-�,_r.�*�.A_._._._._ Date--�'.---�_._� .................. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma=elton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REVISED 8-59 3M 3-'63 F.P.Q0.