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FQR OFFICE USE: r � -, . APPLICATION FOR SANITATION PERMIT Permit .. No. .4... . .. ...... --------------- --------------------- (Complete in Duplicate) -------------- - --------- 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-;2 JOB ADDRESS Ar L CATION .... . ..... -- --------------------------------------------------------------------------------- Owner's NamA/,_//W_.<.c)..... --------------------------------------------- --------------------------------- Phone------------------------------------ --------------------------------- Address.............................. ... .--/. ..... ...........—-----------0"" ; -----------............. Contractor's Name- - -•---- _VCZ:---------------------------------------------------------------------------------------- Phone.. Installation will serve: Residence 6��pa`rtment House [] Commercial E] Trailer Court 0 Motel El Other Number of living units: ___Z Nu V ,p,66r of bedrooms __"'�_ umber of baths ./--- Lot size --- - -- 1- --_-_---------------------- Water Supply: Public system [V Community system El Private [-] Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand [] Gravel [] Sand .Loam Ej Clay Loam 0 y E] Adobe &-<ardpan 0 Previous Application Made: (if yes,date--.-----_---------) No New Construction: Yes o E] FHA/VA: Yes D No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta* Distance from nearest Distance from founclatio -------------------Material----C-0-------------- <....... No. of compartments-------.Zr--_----- ---Liquid depth___-� _z-...._______ Capacity_ 01Z?---- Disposal Petd: Distance from nearest well_-_-_✓Distance from foundation... ........Distance to nearest lot line-n-�..>_.......... umber of lines--------- ------------------Length of each line______ 4 __-___.Width of trench-------e�-------------------------- Type of filter material----1,4__--z,4?t_0epth of filter material--)--Jl......... ....Total length_______ -----------...... Seep it: Distance to nearest well_-________-Distance from founclation/."'.- __e_Distance to nearest lot line.� ❑ Number of pits------- *----------- Lining Size: DiameterS__3_�_/__.-----DeptK� 7"00 Cesspool: Distance from nearest well-----------------Distance from foundation------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------_------- Distanceto nearest lot line--- ----------------------------------------------------------------------------------------------------------------------------------- 4- 41 of I—------------------------ --------------- - ... ................... Remodeliriq and/or re airing Ldescrib-l:------ --- ;57 �4_ -- ------ ---------------------- ---------------- ------------------------------------------------------------------------------------------------------------------------------------ ---------------------- ------- --------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- ---------------------------- �- I I---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,;Sfaf I s, and,4Te-s&p4 regulations of the San Joaquin Local Health District. X (Signed)----- --------- --- -------------------------------------------------------- (Owner and/or Contractor) By:---------------------------- . . ..... -------------------------- ------------------(Title)-61A------ ....... ------- (Plot plan, showing size location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- t G -------------------------------------------------------------- DATE '?----------------------------- ------------------------- REVIEWEDBY-------------------------------------------------- -------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------_--- ------... DATE---------------------------------------------............. Alterations and/or recommen atio s: ------------------------ ---- --- .......................................................................................................... ------- .......... .......e ----------------- --------- ..............................................- ------------------------ ---------- ................... --- --- - - A_ ------------------------ ---------------------------- ------------------------------------------------------------- --- ----- ------- 1-2 ...... --------------------------------- -------------------------- ---------- FINAL INSPECTION BY:------ ................................. Date 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 B-S9 3M 3-'63 F.P.120.