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FOR OFFICE USE: --------------------- ----------------------------------- ----------------------------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..__1._.__...�_._. ------------------- - ---------------------------------- (Complete in Duplicate) Date Issued ---------------------------------- -"_ This Permit Expires 1 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 AND OCATION...101- . � � 1 7 -- �.�`� �� ,�� 1� �------------------------- O wner's Name----- --+-`--"---e'er`-��--•- (� -- Phone Address----- -. �-- -------- -------------------------------------------------------------------•---------••---------------•------- ------- ----- Contractor's Name �'� �' �' ��t � r` ----�------- Phone. Installation will serve: Residence Apartment House El Commercial ❑ Traileer Court ❑ Motel ❑ Other Number of living units: _-T_ Number of bedrooms ---r Number of baths -_`"T_ Lot size XY0----_--..__f_ ------ Water Supply: Public system ❑ Community system ❑ Private D§. Depth to Water Table -1-,5 ff. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ i Previous Application Made: (If yes,date--------------------) No [X New Construction: Yes X No ❑ FHA/VA: Yes ❑ No X 7 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-4W-----Distance from foundation---/�_._----_.Mate rial__ ' C `--------- ----------• Size_ _f 1 Liquid de th_, .:f- __.:______ Ca acit :mo- No. of compartments. }�f--------------- - - - -�r�. q R - - - p Y--- ----... Disposal Field: Distance from nearest wekl__ _Dista a fGo f_o ndption___ ___.Distance to nearest lot.I��re__ ----------- Number of lines_-------------------"--- -- gtCf o ea h lin _ `_ .��:7 ''Width of trench-- -- ___Len Type of filter material.5--_'Depth of filter material__- i-_-_-------"-Total length____ _-___-"______-__-______________ Seepage Pit: Distance to nearest well----------------_-----Distance 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__.___-__-_--"-__----_--_______..__ ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------- Liquid Capacity------------------------------gals. 77 Privy: Distance from nearest well____ __ __-"______________------------Distance from nearest building--------------------______.___-_...__-.._. ❑ Distance to nearest lot line------------------------------------------ --------------•------------------------------------------------------------------------ ------------ Remodeling and or repairing descri e�: y �--- -- �----*- �"'�`�'�` " ------------ "" n ---------------------------- _______________________________h______--______.__....__________--____________________.------_________--____--_____--__---_________-______________--____._-_-_____ ---------- --------------------------------------•--------------------------------------------------------------------------------------------------------------------q-- y ---------------------------- --- - I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, Sta and rules and regulations of the San Joaquin Local Health District. (Signed)-----fi �,Z=r;_'`�'�'-�''"'�---- - -:- --- LL`-z}------ ------`--'°T----------------------------------------------------------------(Owner and/or Contractor) BY:-----------------•----------o ------- --------------------------------------------------------------------------------------(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------------------------------------ ---------------- REVIEWEDBY------------------------------------------------------------------------------------ ---- - ----- ---- DATE----- f= -- BUILDING PERMIT ISSUED---------------------------------------- — — DATE Alterations and/or recommendations------- ---------- --------------------------------------------------------••---------•------•-------------------------------- --------- ------------ --- --- ----- -------- ------- - -•------------------- ---------------------------------•------------------------------------ --------------------- � f FINALINSPECTION BY-.---------------- ---- ---------------------- -------------- Date------------------- ----------------- ----- - ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West Stir Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3rM 3-•63 F.P.120.