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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. r -� i - - --------------------------------------- ------------ -- (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. S49. JOB ADDRESS AN,P,4,0CATI0N-- 1 ,�1�___ Gi_ _v ----------------- Owner's Name----- ( r.-_0.........-• ------- v'� - ---------------------------------------------------.-- Phone-------/------------- ----------- Address------- ................ ... !... C _------- T f � -------------------------------------------------- r Contractor's Name----------- '-------�- -QC� - -----•--L-- . Phone---•---------•----- Installation will serve: Residence ®impartment House ❑ Commercial ❑ Trailer Court ❑Motel ❑ Other ❑ Number of living units: ----P--. Number of bedrooms ___ __ Number of baths I______ Lot size __--`- -- ____ _p^ ______________________ Water Supply: Public system ❑ Community system rivate ❑ Depth to Water Table _____:__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ©hardpa( [l�` Previous Application Made: Ilf yes,date----------------___) No �ew Construction: Yes El No /VA: Yes F1 NO �1 TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well---- ______Distance from feclation_1O_-_____.Material__G4_C_e(?-___S�_-___.________:. No. of com artments.._v�-______________ $ize___ ,X____ _ Liquid de th__.___��// Ca acit I �Q� p � Z.---- q p. #*— P Y Dis osal Field: Distance from nearest well---_'- -_,Distance from foundation___ _ -------Distance to nearest lot line----e-__.____ : p[?]� Number of lines______________ --- ------------Length of each line.-___-_- . Width of trench__y ._ _ jtt g f�-------- .................. -, Type of filter materiaL__I_L _____________Depth of filter material----.�_f____________Total length______________ ____________-_- . Seepage - Distance to nearest well---'�"-----------Distance f m foundation__/a_.�-------Dista�ce to nearest lot iir�e�i_.___._ Number of pits---------1------- ---Lining material----- Diameter__..3,�__/.......Depth c-D_q5 Cesspool: Distance-from 'nearest well_________________Distance from foundation--------------------Lining material__._______________..____._____.__-__. ❑ Size: Diameter-------------------------------------.Depth------------- -------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from 'nearest well-------------------------_._______.___________._Distance from nearest building------------------------------------------ ❑ Distance'to-nearest lot line--------------------------------------------------------------------------- -------------------------------------------------- 1 Remodeling and/or repairing (describe):------------ �--------- �G �� ' ------------•--------------------------------------- ------------ ------------------------------------ P r r, - ------------ --------------------------------------•=------------•-----.----------------------------------------------------------•--- -•-•----------- -----------==--------------------------------- P- • — ....----------------------------------------------------------------------------------------------------------------------------------- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a laws, and r and% tions of the San Joaquin Local Health District. �_7— (Signed) , = ----------------------------- --=-------------------------- ----------------------(Owner and/or Contractor) 1 Title By:._.. `----------------- -------------------------- -[ ] 3 �... [Plot plan, showing size of lot, to ati n of system in relation to wells, buildings, etc., can be placed on reverseidA r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- C� ---- - -------------------------------------------- DATE-------- � 124 REVIEWED BY------------------------------------------- - ------------------------------------------------------------------------------._ DATE--------------------------------------- -------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE----------------------------- -- Alterations and/or recommendations:-•-------- --------------------------------------------•-••-------- --------------------------------•------------------------------ ------ FINAL INSPECTION BY:-.-.....�_.___.. �_ _.__ ;� Date.-..------- 1--- / 6� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 4 124 Sycamore Str$et 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 31A 3-•63 F.F.CD. -`