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OFFICE USE:-..-. APPLICATION TR- SANITATION PERMIT Permit No. ._ p( Q-.?- ' (Complete in Duplicate). 1 7 --.-- This Permit Expires 1 Year From Date Issued Date Issued ._._-_-__l.._.._ ---------------- ------ --- 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 LOCATION 1`---------- '-`-�---- `-fes------------------------------------------------------------ �) ------•--------------- Owner's Name '' ---------- _ . �. ------ -------------- - Phone--:k Y-_t,1 0_� Address-------- y----!��------------ Contractor's Name-•--------------------•-----------'s3 = ------------------------------------------------------------------------ Phone----•------------------------------ t Installation will serve: Residence,K Apartment !use ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/_ Number of bedrooms _.2,---Number of baths _/--- Lot size _--.___..X __�`_— �� _ ------______.._.._ Water Supply: Public system JV Community system ❑ Private ❑ Depth to Water Tabled ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ®, Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {if yes,date--------------------I No [R New Construction: Yes No ❑ FHA/VA: Yes ❑ No o TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within#200 feet.) 1 Septic Tank: Distance from nearest well----_�-__.-_Distance from foundation..._�0.-__-_.Material______ ______ No. of compartments------- Liquid'rdePth----i:Y- . -- Capacity Disposal Field: Distance from nearest well__-_-- ---.-Distance from foundation-------- .Distance to nearest lot line---------�r—__ [ Number of lines-------------------/�-------------Length of each line--- ---_�'o`----Width of french----------------3-�__---.-- ; Type of filter material----A --_Depth of filter mate rial_._,f ' Total length____________________ '_ --.___.__-- Seepage Pit: Distance to nearest well------ --........Distance from foundation------;?--- to nearest lot line--__.--_�---- Number of pits---------/----------Lining material._ ...Size: Diameter--- -..K------Depth_.--__2- --------------- Cesspool: -------------Cesspool: Distance from nearest well_________________Distance from.foundation._-.---.-----------.Lining material-_-.__-----_-_-________-_:_______... ❑ Size: Diameter------ ------- ------------ ----------Depth----------------------------------------------------Liquid Capacity- - ------------------------gals. r Privy: Distance from nearest well-____________________________________-_-_---_-_Distance .from nearest building--.-.- _-----_-_-_-_.-.-__._-------------- ❑ Distance to nearest lot line------------------------------------------------•----------------------------------- -------------------- ----------------------------- / 1 Re odeling and/or repairing (describe):--- ---------------- - `-_-----!_ ------ -- - ---- -�' -.� -- --------------�..=��--'---- -- `'sem---�-g_�=�"-a.�-�-1 ---- ---�-�-'`-'��- --- --�-�_. _�-�--5-� -- - ' 1-p ------ ----------- •- �i - 'GQ~ hereby certify that Ihave' epared this aica�ion and fiat the work will be done in accordance wiSa Joaquin County prth ordinances, State laws, and rules and..regulations of the San J uin Local Health Di trict. t � 51 ned _._.___ _(Owner and/or� r (Title)-- ---------------- �� By:------ -_ (Plot plan, showing size of lot, Ioca ion of system in relation to wells, buildings, etc., can be placed on reverse side). FORD RTMENT USE ONLY , APPLICATION ACCEPTED BY----- -- --- -- . .... ------------=----------------- DATE '/ ----------- REVIEWED BY----------------------------------------- - ------- ----- -- ------ DATE} 4 BUILDING PERMIT ISSUED-------------------------------------------------- I------------ f---------- DATE----------------------------- Alterations and/or recommendations: -------•------------------------------------------------------ ----- ----------------- ---- ---------------------------------------------------------------- --- -------------------------------------- � ��---------------------- ---------------------------------- - - ------ = -------_----------- -------------------------------------------------------------------------------- --- ---------------------- FINAL ------------------- �- FINAL INSPECTION BY:_. .=_W_._-!----- -_-__ ----------------- { Date.... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California 1 9 REVISED B-59 31A 3-'63 F.P.DD.