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FOR ONCE USE: '1r -------------------------- -- °ys �,1'' APPLICATION FOR SANITATION PERMIT Permit No. . ..��r�... ,� (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 OrdinanceNo./549. JOB ADDRESS AND LOCA ON----/ f 1C1' G.rC3T _ ----- Owner's Name /��--_--------- --------- ------------------------•---------- ---- Phone-----------------•-------------- Contractor's Name--------- � �' ' Installation will serve: Residence [,(Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _.l--- N mber of bedrooms ---P-_ umber of baths __Z__ Lot size --__,f 4 �?___`_____________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. 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 ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ 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 from foundation------------.-------Material----------------------.___._______-____._.______- ❑ No. of compartments--------------------------Size----------------------------:---Liquid depth---------------_--------Capacity---------------------- Dispos field: Distance from nearest well---,—'--_...Distance from foundation. __.Distance to nearest lot line__, -__ Number of lines--------- _____________________Length of each line------,�_Q__�-----------Width of trench__.,' "--------------- Type _ �s T e of filter material__ . De th of filter material__ .1� Yp P ��---- Total length----�?---------------------------- r SeeaNumber it: Distance to nearest well______________________Distance fro foundation___ .s,�__.`___.Distance to nearest lot line_o. — -- of pits._.__/.___._.___Lining material__ ___Size: Diameter._0_3_"__.___Depth..��_--__-.-.__-_-_- 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-_________-_.-__________--_._---_-_... ❑ Distance to nearest lot line--------------------------------------------- -------------------- Remodeling and/or repairing (describe):_____.._ ------ ,,/ ---------------•---------------------------------------------•-------------------------------------------•---•--------------------------------------------•----------------• --------------------------------------- ------ --------------------------------------------I----- ------------------------------------------------=----- --------------------------------------------------------------------•-----------------------•-•----------------------••----------•--•----------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I d rules and regulations of the San Joaquin Local Health District. �� (Signed) �ner nd/or Contractor) B : :.L Titley . . . - ---------------- l ' )----- -/---- --- --- -------- (Plot plan, showing size of lot, location sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------ '- -- ------ DATE-----L ---6,-- -------------------------- REVIEWEDBY---------------------------------------------- --------------------------------------------------------- ------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------- ---------------------------------------------------------------- ---------- DATE--------------------- -------------------------------------- Alterations and/or recommen ations:-______._______ ----------------------------------------- _________-_._________-____-_______.__ �' �L `-"----�.--------------------------------- S. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ----------------------------- -----------------------------I------ -------- -------------------------------------------------------------------------------------------------------- ----- ------------------------------- ------------ ------------------------------- ---------- --------------------------- ------------------------------------------------------------------ ------------------------- FINAL INSPECTION BY: 4 -------------------------- Date �1 -� - ` 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 F.P.CO. --4