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F)OR QFFICE USE: ---- -'--�1�-�------- -------- � ..,f...C?--��--- , c� APPLICATION FOR SANITATION PERMITPermit No. _______________________ ______ _______ y ----------- _ '(f U-- (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 Ordinance No. 549. JOB ADDRESS A kLC ATION--------d� T / - --------------------------------------------------------- Owner's Name ------------- Phone------------------------------------ Owner's ------ F � ... ✓1 , + Contractor's Name --------------------------------------------------------------------- --- Phone ------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel` ❑ Other ❑ Number of living units: I.__ Number of bedrooms *I,.- Number of baths Y___ Lot size .__�. -----------_----------------------------------- Water Supply: Public system e 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 2__I�ardpan ❑ Previous Application Made: (If yes,date--------_-----------) No � New Construction: Yes ❑ No Q�- FHA/VA: Yes ❑ No g;.- TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Spti�. Tank: Distance from nearest well __ ________________Distance from foundation ______________._.Material_____________ __ _____-_-.-_________ __.._______- A ` e No: of compartments-------------------- -----Size--------------------------------Liquid depth----------- ---- --------Capacity----------------------- Disposal Field: Distance from nearest well-------------- Distance from foundation--------------------Distance to nearest lot line______-_-________ Number of lines------------------ ----------------Length of each line---------------------------- Width of trench----------------------------------- Type of filter material--------------------_----Depth of filter material----------------- length_______________------------------------------------------ Seepage Pit: to nearest lot line__ _..._ 0 seerp�ag'e Pit: Distance to nearest well-----�'_-..___Distance fromfoundation______� _* Lld� Number of pits------/-------. /• ----Depth- U1 Lining material-_-- _ -� ---Size: Diameter---- ----.- p ------------------ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material...................._______________. ❑ Size: Diameter---------------- --------------------Depth------------------------------------- --------------Liquid Capacity--------------------------..gals. q Privy: Distance from nearest well---------------------- - _--------------------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line--------------------------- ---- - --------------------------------------------------------------------- ------------------ O Remodeling and/or repairing (describe).--.--------------- -- - ----- - --4! -f - - ••------------------ -•------------------------------------------------------ . ---------------------- ------------•------------ --------------•-----------•------------ ----------------------•------------------------------------ ----------------------- - ---------------------------------------------------------------------------------------•------------•--------- ----------------------------------------------•----------- ----------------------------------------•--------------------------------- I hereby certify that-1 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. (Signed)------------------------- ------------- --- ----- ---(QyZM9=RV&'Contractor) BY: ` J (Title)..W_. _...... (Plot plan, showing size of lot, location of system in relati o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ c.,d1- ----------------- ---------------------------------------- DATE---------2 K I- REVIEWEDBY--------------------------------------------- ------------------------------------------------------- DATE--------------------------------------------------- -------- BUILDINGPERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE-----_------------------------------------------------------- Alterations and/or recommendatio :__ __.. -------------------------- ---------- ------•--------------------------- Q1 - - -----------------•---------------------------------...------------••---------- --------------------------------------------- -------------------------------------- --------------------------------------- ----------------- ------------------------- ----------------------------------------- Date. y e �-��_ ----- - ----------------- FINAL INSPECTION BY:.. ------e� ��d--------- ----- ------------- - ��- ---------- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVfSEG 13.59 3M 3-'63 F.P.CC.