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FOR OFFICE USE: ----------- i7�6 6 APPLICATION FOR SANITATION PERMIT Permit No. ................... ------------------------------------------- -------------------------------------------------------- (Complete in Duplicate) ---.._______________________________._---_-..-._-_.___ This Permit Expires 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 described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION•_ 1 ---------- m P,( ~ ----------------------------------------------------- Owner's Name-----•------ . 5 =J---------------f- ....... 1-4----- Phone.................................... Address------------ R�!v -----------1ZC--�--D-------------- TC>C tL ° r`� Contractor's Name--•----••--IR i2AI!-)_4----•------ -=-------------•-•-----•--_--............................................ Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms -------- Number of baths ........ Lot size •----------------------------------•-----_-------__-_---_--- Water Supply: Public system ❑ Community system ❑ Private IN Depth to Water Table .`$T ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Of Hardpan ❑ Previous Application Made: (If yes,date____________________) No K New Construction: Yes ❑ No V 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----------------------- Disposal Field: Distance from nearest well.1-04+'.___Distance from foundation__1e!�...........Distance to nearest lot line._�-f d____--_- Number of lines......... ----------------------Length of each line....------Ip...._._..__._._.Width of trench---_1_Q-'-_--_.--._.---_-_--_-- Type of filter material_SJ_Pc.Y��----Depth of filter material-------1p'.__...._..Total _____________ 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 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) A-k-k--------k�q------' ----------5 •-----------_------------------------------- --•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ ----------------------•-----------------------------------------------------------------------------------------------------•--------------------•-----------------------------•------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ----------- 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 +he San Joaquin Local Health District. (Signed)-------------Vy'4k-A^•r-1--.T^..-- ..Vr*e_-.---------- ---------------------------------------------------•-----------•--------n------- ,(Owner and/or Contractor) -----h �- �sys;em ---------------------------------------------------- Title------` = ---------------•-- - ... (Plot plan, showing size of lot, location tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---�.a „�------ ---------------------------------------------------------- DATE....' --------------------------------- REVIEWEDBY-------------------------------- ------------ -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------------------------- ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- ------------------------------------------------------------•------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.... --.---- -------------------------- ------------------ ------ 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 ES 9 REVISED S-59 3M 3-'63 F.P.CD.