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FOR OFFICE USE: T •------------------ -------------------------------- °' - kAPPLICATION FOR SANITATION PERMIT Permit No_ ________________________ ------------------ ---- -- --- ------- =� » . ------------------------------------ -------' r 54"'On. ..a.. .P{Comple#e in Duplicate} Date Issued -_._--_------------------------- _--- -------.--- This Permit Ex iresa 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 Ordinance No. 549. JOB ADDRESS ANP LOCATION.--�. -�_--to ---_ ---- ---•- ---------------------•---•------------------------------ Owner's Name---- -- ----- --...._ -`-t1! - ----•--------------- ----- - ----- - Phone-------------------------------- Address------ - _.0 l `r4 ----------- 1! Contractor's Name. .T ... ----------------- Phone..--------------------------------- Installation will serve: Residence & Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.�--- Number of bedrooms - - Number of baths I----- Lot size Y -------------------------------- Water - -_-_Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table$79 ft- Character of soil to a depth of 3 feet: Sand ❑ Gravelq❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [R-F1ardpan ❑ Previous Application Made: (If yes,date--------------_-__) No [ New Construction: Yes DRONo ❑ FHA/VA: Yes ❑ No Zj-' TYPE OF INSTALLATIOWAND SPECIFICATIONS: (No septic tank'or cesspool permitted-if public sewer is available within 200 feet.) 1 t t - / Septink: Distance from nearest well--°-__- ---._-Distance from foundation _4_.- 0 Septi --------------- No, of compartments-- __2--_--------_----SizeJ3 ----------Liquid de th__-__ _ _Capacity Disposal ield: Distance from nearest well__—___ __._JDistancerfrom foundation/b_.v-___._-----Distance to nearest lot line---L5---------- F Number of lines---- --- ------------------------Length of each line-- C1-----_ -� --------Width of trench-- ----' ----------.---.-----•-- 5 Type of filter material-_ - Depth of filter material__--Zr------------- length----&o--_.----_.---_----_-_---.- Seepage Pit: Distance to nearest well-----�- _-_-Distafnce from foundation-__�-A-�_..._-_.Distance to nearest lot line��--..--_- [+� Nsimber of pits---t_---------------Lining material_Pll�s-4_ ____Size: Diameter-_-.3t- __4-------Depth.......eZj"_I %+ ---------------- Cesspool: Distance from nearest well----------------Distance from foundation--- material------------------------------ nthi -----------------------_Li uid Capacity r Size: Diameter------------------------------------ De ---_gals. Privy: Distance from nearest well------ I. ...............:...Distance from nearest building.----.----.------_-----------..---.._---- ❑ Distance'to riear6st lot-l-ine------"'""'-----"'""'"" ___--- F .. .. K 7. 46j- Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------------:------------------------------------- ------------------ 1 --------------------------------------------------------•---------------------------------------------------------------------------------•----------------------------------------------------------------------------------- --------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 reg lafions of the San Joaquin Local Health District. (Signed)-, ----------------Owner and/or Contractor B ----------------- -- -------------- • {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 APPLICATION ACCEPTED BY-- ° ---------------- --- -- --------------- ----- DATE__/0_-7-7- -------------------------- REVIEWEDBY-------------------------------------------------------------------------------y--- -------------------------------------- DATE------ ----------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------- ------ ----------------. DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------- - - ------------------ ---- -•------.-• -------------------------------------------•-------•---------------------------------------- -------------------------••--------------- {/;_ ---------------------------------------- Gv¢' .-__ --------------------------------------------------------- --- - -------�- -----•------------------------------------------------------ ------------------------------------------- ---- ------------ --- - ----�------------------------------------------------------------------ -------- ----------------------------------------- ----------------------•---------•---------------------------- ....... ----------------•:--------------•-----•----------------:-----------------------------------------------------------------------------------•--- y FINAL INSPECTION BY:..---- T 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 ES 9 REVISED 8.59 3M 3-'63 r.P.0 / v