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FOR OFFICE USE: G 1 77---- _ _ _ `1--------- ----------__ _____________"-_-_-.-_ -_ -_-"- ".- APPLICATION FOR SANITATION PERMIT Permit No. ..Z....._. j . ys-- _ 7 ---------------- -- -- ------ ------------- --- (Complete in Duplicate) ----------------------- This Permit Expires 1 Year From Date Issued Date Issued ._-.../3 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 Ord' ante No. 549. JOB ADDRESS AND LO-Cr---ATIONI____-____ / �//---- -_"-"-___ Owner's Name------ A - _ -- --- L__ l ---------------�-------------------------------------------- -------------- Phone----------------------------------- Address -----------------`�-�5 --- ----- ------�_ ------- -- Contractor's Name --------------------------------- Phone----------------------------------- Installation = Installation will serve: Residence DrApartment House F1 Commercial ❑ Trailer Court ❑ Motel ❑ Other' ❑ Number of living units: -----t- Number of bedrooms ._ Number of baths I""-."- Lot size -----lt?_,0__Y_-U"9________________"____ Water Supply: Public system r—community system ❑ ;Private ❑ Depth to Water Table .bv ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel EjSan y Loam [-] Clay Loam E] Clay ElAdobe Hardpan ElPrevious Application Made: (If yes,date___---___-_.--_--) No ew Construction: Yes No ❑ FHA/VA: Yes ❑ No , l TYPE OF INSTALLATION AND SPECIFICATIONS: r' (No septic tank or cesspool permitted if public sewej is available within 200 feet.) SepticTank: Distance from nearest well---- ------ Mitance_yfrom__Xfoundation---/1- ,------.Mate Material of compartments_-_-_�--.--_ Si e---- ----Liquid depth----A- - --- ---- . Capacity..... "_. oel : Distance from nearest well------ Distance from foundation _-""--._"_"Distance to nearest lotline_.Dispv Number of lines-----1----------------------------Length of each line-----2_0_"� Width of trench".__2,_f--------------- ------------------------ See _`_____"___"_ Type of filter material__ ?V_(__AC_""Depth of filter material__-f_1"--__-Total length__�D ------------------ Seepa Pit: Distance to nearest well------ ___"""____Distance foundation--lo-----------Distance to nearest lotaine_� ....` ' Number of pits.__"/----_----_---Linin material--_1rC?_�-_ c3� V Lining - -- - '�--- -Size: Diameter--------- - -----Degth- --��--•------------` Cesspool: Distance from nearest well-------------.---Distance from foundation-- .-_--_----__.Lining material---------------_--.-_.------"_---. ❑ Size: Diameter-----.--------------------------------D th_>_ �P ---------------------------------------------Liquid Capacity----------------------------gals. Privt..;.,, y: Distance from nearest well-.---- --------- --------------------------_Distance from nearest building ❑ Distance to nearest lot line------____---_---_ --------------- i Remodeling and/or repairing (describe):____..---------------- I '---------------------------------------------------------------- --------------------------------------------------------------------------------------- ----------- ----------------------------------------------------------- ; ------------------------------------------------------ ------ - - ------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepare is ap ' ation and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and ulatio of the ° n Joaquin Local Health District. (Signed)---------------------- ---------- ' --------- ---------------------------------------------------------------(Owner and/or Contractor) By:-------------------------------------------- -- -------------------------------------------------------(Title)-------------- (Plot plan, showing size of lot, location of system in r latioh to wells, buildings, etc., can be placed on reverse side). FOR DEP�4RTMENT USE ONLY APPLICATION ACCEPTED BY_____ " -------------------------------------- DATE----(--2--" � ------------------- REVIEWED BY ----------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED ----- ---------- DATE. - - - �--�-------------------- Alterations and/or recommendations:-_.-- __CQ- -__._-__t- " ---------- I a �s s- ,.. ------ ------------- --------- - - - ----- FINAL INSPECTION BY:"-.C- ---------------------------------- Date---Z '--)-7-' - ----------------------------------- 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-59 3M 3-'63 F.P.CD.