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FOR OFFICE USE: } ---------------I------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . 5 ------------------ -------------------------------------- (Complete in Duplicate) �O x, - 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 LOCATION..---= -7 4 -=-7'-- '' G ' ` # --�� - - --- Owner's Name '- g_t I'] Phone-_/ --- - - Address -��--v---------------f..-=___e--------> ----------------------------------- ----•---•-------. ------------------------------- Contractor's Name-- e Phone. - �-?O r~ -- ------ -----------------•- •-------- - ------------ -- ----- - - -- -- •--------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I._ Number of bedrooms _Z Number of baths 1.__ Lot size ___ ' ' _________________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __6.0__ ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ . Adobe Ey__1=4ardpan ❑ Previous Application Made: (If yes,date--------- f~ No gr j'New Construction: Yes []—No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND,-SPECIFICATIONS: (No septic tank or cesspool permitted if'public sewer is available within 200 feet.) %Septic nk: Distance 4rom nearest well_________________Distance from foundation---f______--------Material_.______,____-----'_____-_-_________!_- No. of compartments_T____�_____'.___ ---Liquid depth-----4----------------Capacity ' -nom Disposal Field: Distance from nearest well_Y�'�� Distance from foundaf;Pn__ _p---------Distance to nearest lot line_____ Numbof filter material � �___,___,-Length,of,each'line______..__ �__ -?'Width of trench._______ -� "' 1 ----------- Typei materiaL__ !t_ y____DEpth of filter mat erial-------l ___.__Total171 y J Seepage Pit: Distance tornearest well_____________________Distance from foundation________________-_-.Distance to nearest lot line__.. ❑ Number of pits Lin material------------------------Size: Diameter.--------.----- --- ---Depth----------------_-_--:----------- Cesspool: Distance from nearest well------------1---Distance from foundation Lining material____________________________________ ❑ Size: Diameter ---------------------: ---- 1---Depth---------- ------ ------------- - - -------------- Liquid Capacity---------------------- ----gals. (� WPrivy: Distance fromt nearest __________________________Distance from nearest b0cling----------------------------------------- ❑ Distance to nearest lot line----------------------------------------------------------------------- ---------------------------------------------------------------------- Remodeling and/or repairing (describe)------------------ ---------------- ------------•------- ---------------•..._.------- ---------•---------- -----------------------------•--------------------------------------=--------- " ----------------------------------------------------------------- --------------------------------------- ------------------------------------------------------------------------- ------------------------_-----------------------------------------------------------------------------------------------------------------------------------_------------------------------------______-------_------------___ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I? , and es d regulations of the San Joaquin Local Health District, (Signed -------------- --- -------------------------------------------------------------------(Owner and/or Contractor) BY: ------'-------------------------------------------------------------------------------------------------------------------------(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------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------- --------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-------------------------- --------------------------------------------•-------•-------..--------••-----------------------•------------------------------...- ----------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ��— Date . `? FINAL INSPECTION BY: -� . . ---------- SAN JOAQUIN LOCAL HEALTH.DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,CalifornC9_ Manteca,California Tracy,California E5 9 REVI6ED 8.59 3M 3-'63 F.P.CC.