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FOR OFFICE USE: --------------------------------------- --- -------------- Q - --------------------------------------I---- - APPLICATION FOR SANITATION PERMIT Permit No. ------------ l/ 3 -.... -_ --------------------- 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 Ordinan e No4 9. JOB ADDRESS AND LOCATI N____,-2---_q_ �= ------------------------ "'x - Owner's Name----A---•--•----- t�" - ' ' Phone Address-------- 1 .. �. ` ------ TE ------F`'-Q---- ---31�----- I1?T'GI� ----------------------------------------------------- 3 Contractor's Name ------ -- Phone. .... v� Installation will serve: 'Residence bq'"`Ap94ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. _ Number of bedrooms-3___ Number of baths _ - Lot size ----------------------------- Water Supply: Public system ❑Community system ❑ Private [�D-bpth to Water Table Character of soil to a depth of 3 feet: Sand []' Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date_-_________________) No E]_New Construction: Yes ❑ No [J—FHA/VA: Yes ❑ No E9-- TYPE OF INSTALLATION AND SPECIFICATIONS: `�r ( o septic tank or cesspool permitted if public sewer is available within 200 feet.) - Sept' a k:];' Distance from nearest well------------------Distance from foundation_____ ___________Material __.. -------------------------- ^ No. of compartments------------------------ -Size--------- ----------------------Liquid depth-------- - Capacity--------------- --- p �. r 1 p� � A__ ...__.Distance to nearest lot line-9------------- P _____ __.__. pis og F l Distance from nearest well—XV from foundation-O.r Width of trench------ Z. Number -__.____.___ir__ Nupmber of line I------------- Length of each line__ s� Type of filter material_Ta_...S-------------Depth of filter material+ ----Total length---'er _______ _.____ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------ to nearest lot line______________._ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter._._ z 1`...._.'.---Depth--------------------------------- Cesspool: Distance from�nearest well_________________Distance from foundation__.._._._._.__ � e• . _..Lining material.___._ _ ____._.._____._ ____.__. --- . __ ` ❑ Size: Diameter-- ------------ -------------------Depth----- ----------------------------------------------Liquid. Capacity---------------------- -----gals. Pavy: Distance from(nearest..well--------------------------------------------------Distance from nearest building------ ----------------------- ---'-' ❑ Distance to nearest lot line__________________________________ Remodeling and/or repairing (describe)_____________________ -- -----------------• y ---------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- 1 � ------- ------------------------------------------------------------ ------------------ ----------------------------------------------------------------------------------------- ---------------- ------------- 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 r es apd regulations �o� t San oaquin Local Health Districf. ` (Signed)-------------------------- -------------------------------- ------- ' ' ---- --------- ---------=-- -----------'----------------------------------- -----'-------- -----------(Owner and/or Contractor) -•----------------------------- ----------- --- -------------- -------------------------(Title)-------- --------- ''. ---------------------------- .... �. (Plot-.plan•,.showing size.of,.lot, location-of-system in_r-elation to wells, buildings,_etc.,_can be placed on._reverse:stde).�-�^-FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------n-R__ D------------------------------ --------------------------------------- DATE-------ol_p--257_7�65 ---- ------------- REVIEWEDBY-------- --------------------------------------- ------------------------- ------------------------------------ DATE------------------------r---``--•----------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------ -- ----------------------- ------------- Alterations and/or recommendations:------------- ------------ ------------------------------------------•---------------------------------------------------- ---------------------- } --------------------------------------------------------------------------- ----------------- -------------------------------------------------------------- - - - ---------------------- - ------------ ------------------------------------------------------- ------------------------•---- ---- ----------------------- -----------------------------' ' '---------------------- - --------------------------------------------•-------------------- ----.---------------------------------- ------------------------------------------- ------------ - - ji ..................................................... _____..._.______.__. ..___ ___ _ _ .._.__________.__._______---______...._______ _____.._....____-____________.._____...__..__..__._____ T FINAL INSPECTIO - - - ---- --------- --- --'--' - -- Date------------fQ_' _.._------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Naxeltan Av*. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.