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FOR OFFICE USE: -------------------=------------------------------------- _____________ APPLICATION FOR .SANITATION PERMIT Permit No. ------ --------------- (Complete in Duplicate) ?jr 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 com liance with County Ordinance No. 549, .�_. 3--2-5-2-3 � .t1% � --------- r JOB ADDRESS AND LOCATION:/,(fir t. - �- �� P n ' 71f � 1. Owner's Name 7�eo!�3.�f��..=o ma - Phone �---------- - J Address....... �------- = � /- Phone....Name---- =---- Installation will serve: Residence Apartment House ❑,, //Commercial L] Trailerr Court ❑ Motel ❑ .Other ❑ Number of living units: ---I---- Number of bedrooms --"Umber of baths _�/- Lot size __/ ��'�---------------------------- Wafer ----------------- ------Water Supply: Public:system ❑ Community system .❑ Private [ f.Depth to Water Table -� C]ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand;Loam El Clay Loam E] Clay ®/Adobe El Hardpan ❑ Previous Application Made: {if yes,date--..--...__- -------I No New Construction: Yes��o E] FNA/VA: Yes E]`7 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 fr --- Materia#___- �-------No. of compartments---- ---------------•-Sizex_..__C___S___Liquid depth---------------------.----Capacity--I-- -- -0_ Disposal Field: Distance from nearest weEi----6__-_._.:Distance fr m-fo d_atio --. - !Q Distance to nearest lot line.:. ............ j Number of lines----- ] r------------------------Length ofaEh li'n _"`y �� ---Width of trench.- 1 ------------------- Type of filter material 7r'Y G:_-Depth of filter material__/R`!�----- Total length-------li,`1___� --------------- Seepage Pit: Distance to nearest well------------------:----Distance from foundation-----------.--------Distance to nearest lot line-----.--_--.---._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from found ation---------------.---`Lining material__.------__---.------------------.-. ❑ Size: Diameter----- :--------------- ------- Depth--------------- -------------------------Liquid Capacity----------------------------gals. --------------Distance from nearest buildin Privy: Distance from nearest well g ❑ Distancd to nearest lot line- ---------------------•---------------------------------------------------••-.---------------------------------------------------------- --- Remodelingand/or repairing (describe)------------------ -------------------- ----•-----•--- ----------•-------------------°-----------•-----•-----•---------------------------------•---------- -------- --------------------------------------------••--------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule5 and regulations of the San Joaquin Local Health District. .n��vC.( (Signed)_______ _ _ `-____-- ----1 --------_-Owner and/or Contractor Y:------------------------------------------------------------------------------------------------------------=------------------------(Title)----------------------------------------- ..-.. -------------- (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---------- ---------------- -- - ----- --------------- ---------------•---------------------- DATE_----------------- � - - -------------------- J REVIEWED BY------ -----------------•----------- -------------- ----------- ------------------------ ------------------------ DATE-_ _. _HJT. - -- BUILDING PERMIT ISSUED ------------------------------------------•-------------==---- - D./T�E ------------- Alterations and/or recommendations: ------------------------------------ --- - --------------------•------•--- •------------------------------•---------- ------------------------ -------•-------------------------------------------------------------------------------------- ------------ ------ ------------------------------------------------------------------------ -------------------------•-- - --------------------------- ---------------- ----------------------------------------------------------------------------------------------------------- ----------------------------------.--- -------------- - � j FINAL INSPECTION BY:. /' 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 C5 9 REVISED 8-59 3M 3-163 F.R.gO,