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FOR OFFICE USE.. APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ---------------I---------- I-----------7---7---------Z- - (Complete in Duplicate) Date Issued ------------------------------- -------- I 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. k This application is made in compliance with County Ordinance No. 549. -IVIAJI 005_/_5�0_3/ -1 A) A .... JOB ADDRESS AND OCATION--- - ----------- - --- ............ --- -------------------- -------- - --- ----------- Owner'sNa ---- -- N - - ------ .........Phone------------------------------------ -------tw ---------------- ---------------------- --------------- -- --------- Address -- -- ------ ------------- --------------------- - --- ----------- -------------------------------- Contractor's Name-------- -- ----- --------- ---- -----•---------------- Phone-------------------------------- Installation will serve: Residence Apartment HouseCommercial E] Trailer Court L] Motel ❑ Other E] 47c / , Lof-size ------0, _unifs:�-/ -of-bbclnob� NG`mb�6F -------------------- umber,of.living Number ms --- Water Supply: Public system F] Community system ❑El Private__, Depth to Water Table ff. Character of soil to a depth of 3,feef: Sand.E] Gravel E] Sandy Loam E] ciay cam [] 'Cla; El Adobe[] Hardpan Previous Application Made: (if yes,date--------- ----------) No E-] ---New Construction: Yes [] No [] FHA/VA: Yes E1. No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer' is available within 1�200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material-------- -------------------------- ------ El ---- No. of-compartments---- Size---------------------------------Liquid clep�h-------------------- -----Capacity---------------7 ---- - --- 2Dispos ie ,0/,eld: Distance from nearest well....P4P... Distance from foundation--_._:1'Q_----.Distance-------Distance to nearest lot 64_9......... Number of lines' ----Length o. eac e- ------- Width of trench---_=_;7------------------------ _�th' '777 of filter material--" -------I---------- Type of filter material__:, ;_ See Distance to nearest well---_---O-L Distance,frW fiap6dation--- - ---f_�bistance_�o nearest lot line_-.1�57./.- Number of pits---- Lining material_._N5;. „__Size: b-f i mefer------- Depth 1102_57--100"---------- ---------- C; I _ . ---------------Distance from foundation!-------------------Lining material__...._-._.. VAN Distance fi-orri nearest well Cesspool: -------------- Size: Diameter-------------------------------------Depth----------------------- ----------------------------Liquid: Capacity--------------------------•-gals. Privy: Distance from nearest well_______________________----_____._----_ __.-Distance from nearest b,uilding------------------------------------------ ❑ 41 Distance to nearest lot line-----------------------------------1"7-- ---- _- -----------I------------------------------------------------------------- 111Z�l Remodeling and/or repairing (descri ' -------�7--- -----I----------•- G_ -- 10 _�;�--- ---- --------------------- - --- - x-- " ------- --------- -------- ------------------------ ----------------------------- ---------------------------__111�1 ----------------- ------- -- ------------------------------------------------------------------ -------- ----------------------------------------------------------------- -----------------_----------------------------------------- ------------------------------------ - ------------ --------------------- - ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ --------- --------------------------------------- I hereby certify that + I have p'r ared thisapplication and that the work will be done in accordance with San Joaquin County r ordinances, State laws, and rul, _n regulations of the San eJoa * ocal Health District. 'Sfricf. (Signed)---------------------------- ---------------- --- ---------- --------- --------- -----------------------........._��er an�dor Contractor -- ---- /or Contractor) ------- ------------------ ---------------------------- - --- ---- ----- By:-------------------- -- -- -------- - 11� 'tE (Plot plan, showing size t. location of system in relation to wells, _uilidings, etc., in be placed�'on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----------—------------------;---------------- DATC!007� ------- 'Ll----------------------------- REVIEWEDBY----- ------------------------------- ------------- ----------------------------- ------------------------------------------- DATE------------------------------- -- ---------- BUILDING PERMIT ISSUED------------------------------------------------------------------------:--------------- ---- DATE--------------------------------------- Alterations and/or recommendations:-------------------------- -------- ---------- -----------------------------------------------------------------I----------------------------------- ---------- -------•------------- -------------------------------I------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I--------------- -------------------------- ------------------------------------- ---------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------I---------- ----------------------------------------------------------------------- -------- --------- - ----------------------- -------- FINAL INSPECTION - -------------------- Date.... ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelion Ave. 300 West Oak Street 124 Sycamore Street 3 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-59 21M 3`63 F.P.rD.