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FQR OFFICE USE: - ------------------ ------ ---- _-.� -�� ------01A-- -- -------(... ... APPLICATION FOR SANITATION PERMITPermit No. .....[_t°_ l._._ -------------------- (Complete in Duplicate) Date issued --`�--�------____-- This Permit Expires 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. s'unrt _ 11��/� 6 �2 ----_Q1 _. 1 JOB�AQQRESS AND L ATION------ �---------------�J-`----------•---------- �•-------�---'. .-----1�--- - --- - --- - - � Owner's Name-------- -------- w ---------- Phone-----=------------- Address '--• -----•------------------------------------------------------------------------------ *..........•-------- --------------------- Contractor's Name--------- -/ .� t � - ---• --- ----------------------------------- Phone. Installation will serve: `Residence Eg-i partment House ❑ Commercial.❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ :. Number of bedrooms -_ Numb 6r ofabaths ----/_ Lot size __ ---------------- ____________ Water Supply: Public,;system ❑ Community system ❑ Private 0 (Depth.to Water Table ft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loa ;❑ Clay Loam ❑ Clay ❑ Adobe&?-nardpan ❑ Previous Application TION.AND 5P CIF[CATION�� No ,�' New Construction: Yes Z;.--No FHA/VA: Yes No TYPE OF NSTALLA ❑ (No septic tank or cesspool permitted if public sewer-is available;within 200 feet.) Septic Tank: Distance from nearest well--_-'^' -----Distance �p fah ndation_--�1 r_.__.M t fsl._C�-_ / r__ q pyo ------- ® No. of compartments ___-A---------------Size�� _ Pl:°_----Liquid depth---- �---------Capaci#Y-- -- �,a----- - Disposal Field: Distance from nearest well____:-�__-_-__._.Distance from foundati �ny_ -149----._.Distance to nearest lot line____-.---_- [ Number of lines.______f__._ _ Length of each(line___0, �-- Width of tren&-. i..__________________________ Type of filter material/ -Depth of filter erlal- TotaE lengthy--- . Seepage Distance to nearest well---- -------DistanZejrm fa ndation__ 1 _____.Distance to nearest lot iine_�-_.�------- Number of pits.---1-------------Lining material_,oA —_-)Size; Diameter_..� ---------Depth_1AP7Z---------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- to ❑ Size: Diameter----------------=------------------kDepth--------------------------------------------------.-Liquid Capacity-----------------------------gals, Privy: Distance from nearest well-------------------------- -----------------------Distance from nearest building.-._-._-_-_-----_-_---,--_------_-_--..._. ❑ Distance to nearest lot line- ------------ --------------------------- --------------------------•------------- -- -- ----- - p . Remodeling and/or repairing (describe):- J •---------------- -- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- I hereby certify that l have prepared this application and-that the.work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations o +he San Joaquin Local Health District. ' I ' - (� Contractor)(Signed)--------- ----------- - - BY: r - - -------- -- -----{Title)--- -s---- ---- --------------------------------------------------------------------------- --- --- - - (Plot plan, showing size of lot, location of system in re ..to wells, buildings, etc., can be placed on reverse side). F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- f .t c"`� -------------------------------------------------------- DATE-------------1 — .---------------------_' . REVIEWEDBY------------------=---------------------------------------------------------------------------------------------------------- DATE----------------------------- --- - ------------------------- BUILDING PERMIT ISSUED _ ___ _ . ' ------------ Cr) .DATE -- -- CAlterations and/or recommendation -S_-__ _--- -.- - _ ------------�_________ ____ -- x --------------- - } - -- --- = ' ------------ --------- ------------------------------------ /�-�' --------- FINAL INSPECTION BY-------- - -- --- ------ -------- ---- - ----------- --- Date I -1 ---- -- - ----- ------------------------ SAN JOAQUIWLOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3-'63 F.P.CO. 1 _�