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F R O FICE USE: -------------------------------------------------- __-- APPLICATION FOR SANITATION PERMIT Permit No. ..17, _._ -------------------------- - -------------------------- (Complete in Duplicate) �j This Permit Expires 1 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 OCATION ------ --------------- ------------------------------------------------ Owner's Name ----- �---------------------- ----- -- -------------------- -------- ----- Phone------------•------------•-•---- ----Address---- yi PhoneConfracor's Name------•- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court❑---Moo�tel�o--,Other C]Number of living units: __ ___ Number of bedrooms _S._ Number of baths _l____ Lot ize - /-� Ll -- ---------------------------- " Water Supply: Public system ❑ Community system ❑ Private ZKDepth to Water Table - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe e--pardpan ❑ Previous Application Made: (If yes,date--------------------) No ®/ New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No c -- 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-----------------Distance from foundation--------------------Material___--...___.___.__.-____---___-_-__.______._. No. of compartments------_-------------- Size-----------------------•-------Liquid depth--------------------------Capacity---------------------- �7 40--------Distance to nearest lot line__$.---____-- GDisposal./Fie4d: Distance from nearest well-- from foundation.___ ]�L ---------- ----- ----------------Width of trench.-1-9------------- ---- Type Type of filter __A*CDepth of filter material-_--,`ek-----Total length------Z,*__/----------------------- Seepage Pit: ______________________See agePit: Distance to nearest well_.._ /_ _ __. ..- Distance from foundation_r ___'_Distance cto nearest lot lin�__�__�..-. W [ � Number of pits____ _-----__-___Lining material�.Q�___Size: Diameter__5_3. _ ......Depth_./�{.v1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth--------------------------------------------------.-Liquid Capacity--- ------------------------gals. S I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-___.--_--_--_________________-.------- .f ❑ Distance to nearest lot line------------------------- 3 " Remodeling and/or repairing (describe ------------------ii?�� G`J�'r� �` c7 -------------•----•-------------------- ------------------------------•---------------------------------------•---•------------------------------------------------------------ ---Q/ ---------------------------------------------------------------------••-----------•---------•--•----------------•------------•-------------------•--------------------------------------------------•--- ----------------- 3 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsaandrule and regulations of the San Joaquin Local Health District. (Signed)--------------------- ' = - ( od or Contractor) By:-----------------------_--- ------ -- - - - - ----------------- -- --------------------(Ti (Plot plan, showing size of lot, location of system in tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ---------------------------- DATE--------- ---------- ------------------------------ REVIEWEDBY--------------------------------------------------- -------------------------------------------------------------------------- DATE--------- -------------------------------------------------- 'BU DIDING PERMIT ISSUED-------------------------------------------------------------—-------------------------------------- DATE:------------------------------------------------------------ Alterations and/or recomme ation :_-____-- ------------ --------------- --- --------- k ----- --------------------------------- , Ems.. O�<`` ' ` ----�7,00�-------------------------------------------- ---•--------------------- ------------------------- FINAL INSPECTION BY:........... ^.'-��'_______________ `� Date------. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Avf. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED B-59 3M 3-'63 F.P.CC.