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FOR OFFICE USE: --------------------------------------------------------- APPL CATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Q — L4 ------------------____------------_----------------------- 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, , _--. lY._.._-- Owner's Name_ __-4 ----L� -------- ---- -- _. ..--- ----- -•• -------------------------------------------•--•--- Phone.................................... Address--------- . ... .. _. . ....1 ..........-- ---- .01 Contractor's Name.----.-- '� c -- ---- ---- . ----• .��.. ................ Phone.................... `...- Installation will serve: Residence F] Apartm t House E] Commercial F] Trailer Court ❑ Motel E] Other (1' dam✓7 Number of living units: -------- Number of bedrooms -------- Number baths -------- Lot size ------------------------------------------------------------ Water Supply: Public system ElCommunity system [Ivate Priepth . Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam'1 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date-----___...-------) No ❑ 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.) E � Septic ank: Distance from nearest well 0 _Disq&jLfoundaon `a Material1 - --No. of compartments._.-_--,�- _____-- Siz1__XS__Liquid depth__`f. .. .._._ ___ Capacity Dispos field: Distance from nearest well--t5e.--- Distance from foundation....Z4-----------Distance to nearest lot line..,....../!_.... �1P Number of lines.........—0--------------------Length of each line......... _-----___.Width of trench..__,_ ,_._. ........ fi Type of filter material___ th of filter material------. ._Total length------ h--------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- Number __-_- _--__-- Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from'foundation-----.--------------Lining material---------------------..__._..__..... ..j ❑ Size: Diameter---------- --------------------------Depth---_------------_-_------- --------Liquid Capacity............................gals., �•f' Privy: Distance from nearest well----------------------.------------______________Distance from nearest building_.---------------.--__-_-----_------_-_._. ❑ Distance to nearest lot line---------------------------------------------------•----------------------------------------------•�-----•----------------------------------- Remodeling aia4e* Fap&4*Ast (describe):__- 'r _. c /O_-Seg-- ---------- 7-- ---------------------------------- ------------------ ------------------------------- .......------------------------------•-------------------.---------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County � ordinances, Stat laws, and rules and regujiof the San aquin Local Health District. (Signed)- ----._ , ----_.--------------------------------------- .. ---- ---__ -- ita+prand/or Contractor] gY• -- A----- -------------------------- --- - - - ---( 1 e 4 -- -- ----- - - ----- --- (Plot plan, showing size of lot, location of sn relati to•wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -----------------------------------......................... DATE...,Q_'_y'G REVIEWEDBY----------------------------------------------- -------------------------------------- -------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED....................... DATA --- --------------------------- Alterations and/or recommendations:._.. -------- T� f-4_r -------•------------------------------------ --------------------------------------------------------------------------------------------------------------------------•••-------•------------------......-----•......-----•-•--••.•-----•---- ---------------------- •---•----------------------•--._._...•--------•------------------------------------------------------------------------------------•-------------- ---------•-----. ------------- ..................................... --------------------------------------------------------------------------- ------ ---------------------------------------------------------------------------------------------------------------------- ------------------- FINAL INSPECTION BY:.. ___-------_. Date---- . . _.-�3 - --- ----------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3•'63 F.P.RD.