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FOR OFFICE US�: z� ` ---------------- -----------------------------------------------_-------- APPLICATION FOR SANITATION PERMIT Permit No. .,��. ..7. ------------------------------- (Complete in Duplicate) / ----------4�------------ Date Issued ---- ----- ---- --- - This Permit Exbires 1 Year From 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 LOCATION_.-___.. ----__ --_-_ - ------------------------ Owner's Name ~ Address--•---------•--------•-- R r- - ---- -- - ---------------------- --------------------------------------------- Contractor's Name------ __Ly��...._ �j-�, Installation will serve: Residence ©partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: 1��nity ----- r of bedrooms :�%- Number of baths _�_._ Lot size Water Supply: Public system system ❑ Private ❑ Depth to Water Table ------ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ San oam ❑ play Loam ❑ Clay ❑ Ad be ardpan ElPrevious Application Made: (If yes,date----_.------_-_-.-) No New Construction: Yes E] No HA/VA: Yes ❑ No E - 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 _._._____._-_____...___.__.____.____.-__-___.__.. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity----------------------- Disposal d: Distance from nearest well_- Distance from foundation_,/_l�_- ...__.Distance to nearest lot line_.._ -__�__ Number of lines-__-____--__1_._----__---__--Len Length of each line_--__- .__ ` �� 9 �_: ----.Width of trench' . T f Type of filter material__.��Z_�c-_i�Depth of filter material_ 1--�- ------.Total length_--.-0_� b. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_-----_--_-___.._ ❑ Number of pits.--------------------Lining material---------------------Size: Diameter-----------------------Depth-------------------------- ------ S 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 N ❑ Distance to nearest lot line---------------------------------------------- • ► o Remodeling and/or repairing (describe): ------------------ & _.- cry CNS✓/._Cl t�J'J ------------------------- ---•----------•-----------•-----------------------------------------------------------------------------------•--------------•------------------- --•-------------------------------------- -- ------ -----------------------------------------------------------------------------------------------------------------------------------------------•---------------------•-------------------•--------------------- - - -- -- --- --------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawnd rules and regu tions o the San Joaquin Local Health District. ($igned)--------------- --- __/-: _____------- .-_-_l�?J_- /� ----.-(Owner and/or Contractor BY:----------------------- ---------- ----�-�--�-- .(Title)-----�-1��/-�-�.� - - ------ --------------------------- ----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------C-------�C -------------------------------------------------------------------- DATE----- 16.=_ b__ REVIEWED BY--------------------------------------------------- ----- . BUILDING PERMIT ISSUED----------------- - DATE ---------------------------- Alterations and/or r comma atipns•----- -•-• --------•--•--------------------------•------- --- Y—�T------------------------- -------------- --G �= rz P— - ------------�-`-7 -------------------- -------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:--- ------C._r_- ------------------------------ 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 8-59 3M 3-'63 F.P.CD.