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FOR OFFICE USE: - ------------------------------------------------•- --------- --------- ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------- ..��.1. 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 and install the work herein described. This application is made in compliances with County Ordinance No. 549. JOB ADDRESS AND LO ATION--- ..... -- ---- - --- -------- ------ O , ................ Owner's Name 1 Phone Address-_ ----•-• --------------------- '�- ..__�. -------__- -- - -- - _ Contractor's Name__ _...-__ , ` ,� -------- --.. tl.---------------------------------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑]Motel ❑ . Other E( Number of living units: -------- Number of bedroom----_-- Number of baths Z- Lot size -----2�-------------------•----_-----_____-_---_--_•-----_•_ Water Supply: Public system ❑ Community system ❑ Private Fr-16'epth to Water Table;.?j,3 ft. Character of soil to a depth of 3 feet: Sand Gravel Sand Loam ❑ Clay Loam lay ❑ Adobe❑ Hardpan P ❑ ❑ Y 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.) Septic Tank: Distance from nearest well----_------------Distance from foundation--------------------Material---_-------------------------------_------____ w No. of compartments------ -------------------Size--_--------------------------Liuid de th__-_--_---_-_.___-.---_Capacity t DIspQ;�l �Sld:' Distance from nearest -well $ -��`' ._.Distance from foundation----1�.0---_____Distance to nearest lot line__._____._. tt �h� Number of lines-------------- _______ ________Length of each line________g f? „ Width of trench___�iQ -__--._-- --_-. 'Type of filter material_ _ _ _ _ epth of filter material-------- __.........Total length______.�?1v._:________________________ See a p giv Pit: Distance to nearest well--------�. . _Distance from foundation____ ..__.......Distance to nearest lot line_..__.___._ Number ofp'Its---._-_ /------------Lining mate ria l__,,4,g7t4ii___-Size: Diameter----.___---------Depth_____t.3._______.__.._..__ Cesspool: Distance from nearest well-----------------Distance from foundation-.-------- --_-_-.Lining material-____-----__-_.-_-----------_.-----. ❑ Size: Diameter--------------------------------------Depth---••--------------------------- -------------Liquid Capacity-_----------------•-----..gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.___--_--_-.---__-_-_•--•_-.--.._--.--. Distanceto nearest lot line----------------------------------------------------•----------------- ------ --------------------------------- -------- --- --------- Remodeling and/or repairing (describe): .____FZ_00 ___;"_e4_-_ L C, ----- ------------ - •-----•-•------------•-------------••-------- ---•-- -----• -- ------------------------------------- ----- ------------------------- ----------------• ---------------------------------------•-----------------------------------------------------------•- --- ------ -------------- I hereby, certify, that 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 the San Joaquin Local Health District. --------- (Signed)-------------•L-td ---- (_ _ . d/or Contractor) BY� ------b-tr -----------------------------------(Title)--------- ---- --------- (Plot plan, showing size of lot, location of system in Qlation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -------------------------------------------------------- DATE----z�` 9.1,9_ '>------------_----------- REVIEWEDBY------------------------------------------------------------------------------------ ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------------.-------------------------------------------............................................................. --------------------------------------------------------------•----•---------------------------------------------------------•------- -----•----------------------------------------------- ---------------------- ------------------------------------•-•••-•--•------------------------•---- ----------------------- -------------•--- ---- -----------------------------•------------------------------------------------------------------ ------------------------------------------- ------------------------------------------------------------------ --------------------- ------------------------------------------------------------------------....... ----- ----••---------------- ------------------------------------------------------------<--------------------------- ---------------------------------------------------------------------------------- FINAL INSPECTION BY:.L:, ' = T --------------- 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 96 9 REVISED B-59 3M 3-'63 F.P.CD.