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t-UXXU�HCE USE, f ----------- -------------------------------------- ----- --+--------------- __-___-____ APPLICATION FOR SANITATION PERMIT - Permit No. ..f__ (.�-. /.� - ____ -___ (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 apd install the work herein described. This application is made in corn fiance with County Ordinance Nw 549. (� JOB ADDRESS A LOCATION_ Owner's Name---____ - - ---- -----------Address------------- Phone ----�•*��.._. _ � Contractor's Name______ -- ----------------------------------•• • ---------•------------------------•-•------- - •--------- - -------------------- Phone__.. Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other El fNumber of living units: -------- Number of bedrooms -------- Number of baths __-2,__ Lot size --- waferupply: Public system ❑ Community system ❑ Private �ep-th to Water Table _bft. Character of soil to a depth of 3 feet: Sand ❑ Grave! ❑ 5an y Loam E] Clay Loam ❑ Clay [I Adobe�ardpan ❑ Previous Application Made: (if yes,dot e-___.__--_---------} Na New Construction: Yes Vo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank.or cesspool permitted if public sewer is available within 200 feet.} Septie'Ten - Distance from nearest wel ----- --------Distance from foundatio_ -q r 'jp No. of'com artments-'_--_-- `�` Material_-. ----------- !__: -C •.. �`� � p �.- -------- --Size__��_''�_Co_ � � ---------Liquid depth---------- ----------- Capacity--/fid I Disposal Field:- ' Distance from nearest wel -Distance from foundation__lV------------Distance to nearest lot line___--_�,-_ ' t Number of lines__ ------ -----------------------Length of each line--- of trench_2� ______ Type of filter material�OG_-¢_---- Depth of filter materialt,R" / t 'y ------------------Total length_ =-------�=��-�----------- ' "seepage Pit: Distance to nearest well_1C � --___Distance from foundation___ -_q_,_-_ ` l _____.Distance to nearest lot line___._/•.-_--- Number of pits-. ---------------Lining material.--�G-�-----Size: Diameter__---- _-4-- ------ � s Deptn-- _�----------------•t Cesspool- Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------- _______-__,__-----_ -T------------- , ❑ Size: Diameter------ ---------- --------- --------Depth--- - ------- --------- - --- - ----------------Liquid Capacity_---------------------------gals Z Privy: Distance from nearest well____._-___-_____-_____._____________________Distance from nearest building ❑ Distance to nearest lot line__------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing [describe);------3_/.1LLrz1 ----- ----------- ----------------- ----------------------------- ---------------------------------------------- -•-----•-----•--------------------------------------- ------------------ ----------- =------------------------------------------ --------------------- - I hereby certify that i have prepared this app'cation and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ion f the San Joaquin Local Health District. t (Signed) _ - -- 9 I --------------------- --- ------------ ------------------- ----------------------- ----- ----- _ - (Owner and/or Contractor) �. -- - ---- --------- - ------------------------------------------------------------(Tttlo)--------- -------------------------------- I (Plot plan, showing ca i of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____._--_ -___._-- -- _-- --` __- DATE------� - _ - ----------- REVIEWED BY----------------- -- - ----- - -- __ DATE---------------------------------------------------------- -- ------------------------------------- -------- - :. --------------- BUILDING PERMIT ISSUED -------------------------- �_ti----------------------- DATE c Alterations and/or recommendations:___-----: --------i--_-------- ---r - r -------------------- ---- - - FINAL INSPECTION BY :_-_-. 2/'--_-- -- ----- ------- Date-- -------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodir California Manteca,California Tracy,California ES 9 REVISED 9-$9 3M 3-'63 F.p,CO. +{� l