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FOR OFFICE USE: "� - ----- ------ f ---- APPLICATION -FOR SANITATION PERMIT Permit (Complete in Duplicate) - -------------------- µ This Permit Ex ires 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_descrbed. This application is made in compliance with County Ordinance No. 549. :�-•,�,ni JOB ADDRESS AND LOCATION- ----------------------- Owner's Name--- ; j Phone - •--� ! Address I_` . ._. '�cfLi L! __._g ----------•----------•---------------•--------------------.---- Contractor's Name- �` •------- -------------------------------------------------- 0--• -------------------------- Phone--------•-------------.. Installation will serve: Residence U partment House ❑ Commercial [:] Trailer Court ❑ Motel [:1 Other Number of living units:.___rNumber of bed ___ rooms __? Number of baths _ _ _ _._ Lot size --------_ Water Supply: Public system.❑ Community system ❑ Private 0, Depth to Water Table 4151ft. Character of soil to a depth of 3 feet: Sand 0 Gravel Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe C3 Hardpan E] Previous Application Mader (If yes,date................._.) No New Construction: Yeses No ❑ FHA/VA: Yes ❑ No 3 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-._�s U__.Distanye ror�fgundation____._/(�______-Material_______ ' No. of compartments-_.___- __.__5ize__77<t''z_ �7_, _ "(� __ _ _ Liquid depth____._- - - __-Ca aci l yl� y' -- p tY Disposal Field: Distance from near st well...!- d ff ! Q Istance from f�und�#ion _:/ _ Distance to nearest lot •�4e_ Number of lines__. _._, a - g GI $'f>— C1 - • ----ter ----------------Len th of.each'fi e_ Width of trench - - --� �� .Type of.filter material-5-1--l-?le—K-_ Depth of filter material__/_2---------------Total length....... Z/-D N 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 foundation---------------------Lining materia!......._.______----__.______-__ ❑ • Sze: Diameter Depth -------- --- ---- ---- Liquid Capacity gets.; • 1�'- - ---- - _x�C-ru�.eT�r.-y-r. r.rltwf �' _ -a .�_ ----- -_ + _ _ • p. a.... Privy: Distance from nearest well_____ _._.._ - * � T �`'"�'""`•-- - _Distance from nearest building_----------------------------- Distance to nearesta got line____ ------ ---- -- ----------------- --•--------------------------- ----- Remodeling an /or repairing (de tribe):-------- = -. - - _ - -- v ____ ------ --------------------- -- ` ----------------------- --------------------------------------------------------------------------------- 7 ----------------- 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 rules and regulations of the San Joaquin Local Health District. Si nedt t -------- ----------------------------- -•• -------- --------------------------------------------------------(Owner and/or Con rat or� BY=---•------------- Tale ............................ ..... (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 #I` APPLICATION ACCEPTED BY ---=----------------------------=------------------------------------------------------- DATE_ :> REVIEWEDBY --•---- -------------------------------------------------------------------------------- DATE I1 BUILDING PERMIT ISSUED--------- x f --------------------------------- ------ DATEJ_L-- . ----- Alterations and/or recommendations_________________..__,---------- _ - ------------------•-------------------------------------------------------------•------------•------------ ---------- ----._ . ----------------------------------- --------------------- ------------ .......------- --------------- -- - ------- ------•-------------- ---�---- ----- ------- INSPECTION BY----------- ------ --_-:-- - - ----------- Date ------------ __ ---- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Streets 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3•'63 VF,DD. fi w