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FOR OFFICE USE: ------------------------ ---------------------- AAPPLICATION FOR SANITATION PERMIT Permit No. ....... ............... . ---------------------- -- ------ -- (Complete in Duplicate) -! C --__ ------------------- 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. C.. F_ JOB ADDRESS A D LOCATION_Rli!C'-0_AV.e--- -----`c-- Owner's Name•. 'Q A .-_. one `J'6Z ,I t + " Address_,a3-A_n.,N_j----- - ,��pcz� Contractor's Name_%,. 't.. 1--------------------- - Phone... '�lC�_�d�� Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Is Number of living units: .-/-__ Number of bedroomsC!'�- Number of baths ---/. Lot size __. a••---------------------------------- Water Supply: Public system ❑ Community system ❑ Private 2"Doepth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel❑ Sandy Loam 0KCIay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date------_-------------) No ❑ New Construction: Yes MoO'No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public siwer is available within 200 feet.) pti Tank: Distance from nearest wells�..Q.'---Distance from foundation__-1_�_._____.Mat na--- Se �iLt.�._��_ P* No. of compartments---P---------------- 3!)(_5V-C_ _-_ Liquid depth..-.'_ --Is--- Capacity... _Size. _._. QlL �i, Disposal Field: Distance from nearest well.-&jO-'- Distance from founclatio y_.41.0!_...Distance to nearest lot line---/ _ .__. j� Number of lines._" ____________--------_______Length of each line__7�_��.QerZ�Width of trench._. ------- $ _...__�___ '/ ' Type of filter ma erlal Depth of filter material-._. oy � �2 -------- Total length Pit: Distance to nearest well_____-__--.__--______Distance from foundation....................Distance to nearest lot line----------------- , ❑ Number of pits______________________Lining material---------------------..Size: Diameter__-__--_--.-.---------Depth----------.------------------------ Cesspool: Cesspool: Distance from nearest well----------------- from foundation-.-.----------------Lining material__-___-_____•-_____----------------. �'► ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-.-------------------------- gals,iq Privy: Distance from nearest well-------------------------------------------------Distance from,nearest building-----.-------------.________-._____-_--_- ❑ Distance to nearest lot line-•r-------------------------------------------------------------------------------------------------------•----------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------- ............................................................. -----------------------------------•--------------------------•------------------------------------------------ .-•-------------------------------------------------------------•---------------•----------------------------- r ------------•--------------------------•-•----...................----------------------------------------•----•---•----------•---------------------------•--------•--•--•---••-------------•-•----------•------------------ 1� ----------------•------•------------------------------------•_.----•---------------------------------•--------•------=--------------------------------------------------------------------------------•--------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County - ordinances, State laws, and rules and regulations of_^tthe\ San Joaquin Local ealth District. Si ned ; - (GAN Contractor) By:............. • - --------------------------------------------------------- -�----- --- (Title)------- ----------------------------------- ---- --------- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). --�- Q FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -----------------------------------------------------------------------• DATE------ � ------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED............--------------------------------------------------------------------------------------- DATE----------------------- ------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------------------•------------------------ --------------------------------------------------------------------------------------------------------------------:------------------------ ---------------------------------------------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- -------------------------------------- ------ --------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTIOTI Date -�_'_(2 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 13-S9 3M 3-'63 F.P.CO.