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FOR OFFICE USE: -------------- -- - -- ------ ------------ ------------- { APPLICATION FOR SANITATION PERMIT Permit No. ---1A!.3_... -------------------------------------------------------- (Complete in Duplicate) ------------------_-----------------------------------____ This Permit Expires 1 Year From Date issued Date Issued ...Zo.r/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and i stall the work herein described. This application is made in compliance with County Ordinance No. 549, f( �/�J ., 1! bSU--oe - JOB ADDRESS AND LOCATIO/N_1!/ /° ,!_____""_u� __ .__.__.... t___ Z _ � _ _t___ ` Owner's Name----------- 1- •- - • --------- �"- -�-_'_'_----------------- = ---------------------------------------------------------.-. ne-----•------------------------------ Address-••------,�n� .. � Contractor's Name---------------------------------I------------------------------------------------------ ------------------------ Phone----------------------------------- I Installation will serve: Residence ❑ Apartment House ❑ Commercial ®o aile Court ❑ Motel ❑ Other ❑ ` Number of living units: -------- Number,of,bedrooms ________ Number of baths off/___ Lot size slg!r L_o_________________________________________ Water Supply: Publics stem Community,system Private Depth to Water Table &.f. ft. r Y � Y• Y ❑ ❑ P Character of soil to a depth of 3 feet:t Sand ❑ `Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--.-------- ___._} No ❑' New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- rm (No septic tank or cesspool permitted if public sewer,is available within 200-feet.) �} Septic Tank: Distance from nearest well--- ------------Distance from foundation--------------------Material-------------------------______________________. Dis❑osal Field: Distance from depth--------------------------Capacity-----------------____-- � p - � stance from foundation-_-_.---______-__.Distance to nearest lot line________________ ❑ Number of lines---------------------------------�Length of each line------------------------------Width of trenEh----------------------------------- Type of filter material______________________I-Depth of filter material-----------------------Total length------------------------------------------C Vf : Distance to nearest well._l_J'$_'_.___:_Distance from foundation_oed-----------Distance to nearest.lot line_��________� Number of pits--f----------------Lining material- Size: Ammer--a'r'¢. - ___Depth----P_'----------_----------_1P 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.------___.___________________.._-_..__ F ❑ Distance to nearest lot line-------------------------------------------------------------------------------------- -------------------------------- Remodeling and/or repairing (describe): -------------------------------- -.: . ----------•--------------------••- I --------------------------------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San-Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ ------ -- ------ / -- ---- ----------- ------------------------------------------------------------------- ------(Owner and/or Contractor) •-�. : (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-- ----------------- ---------- REVIEWED BY-------------------------------------------------- ------------------------------------------------•--• DATE------ ---------------------------------------------------- - BUILDING PERMIT ISSUED------------------------------------------------------------------------- ---- ------ DATE.------------------------ Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------•--------------------------- ----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------••---------------•---------- •----------------- ----------------- ------------ --------------------------------------------------------------------------------------------------------- -------------------------------------- FINAL INSPECTION BY:-"-4 - #---------- Date_f '. ,r ------------------ - ------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E$ 9 REVISED B-59 3M 3-'63 F.P.CO.