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FOR OFFICE USE: ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. -_.. -- - (Complete in Duplicate) _.- This Permit Ex .res 1 Year From Date IssuedDate issued ____�1��21� ;o Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thisapplication is made in complianc with County:Ordinance No. 549. J013'i ADDRESS AND JOCATION Own(er's Name ----------- Phone. Address------- � ." - ,/ Contractor's Name- - - -----" ------'-•----- M-------------------------------------------------------------- Phone------------------------ InstaEation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Others .y_,-} l ` Number of living units: _____.Number of bedrooms._-____- Number f baths ---1---,Lot size ______.. �-��___.�Q�P___t�(z,�� �.., r Water Supply: Public system ❑ Community system.❑ Private depth to Water Table /00 ft. Character of soil to a depth of 3 feet: Sand ❑'i; Gravel 0 'Sandy Loam ❑ Clay Loam ❑ Clay ' Adobe❑ Hardpan Ef .-...-_ Previous Application Made: (If yes,date------------------ :.)",No❑ . New Construction: Yes ❑ No ❑ PHA_VA: Yes._0_No❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 ' - l � [ F. (Na septic tank cesspool permitted if public sewer is available within-200 feet.) Septic ank: Distance from nearest well----• >�_----_Distance�from�foundation__.__�----______.Material____ __________________------- No. of compartments_-__--�Z_}------_Size-_j_,�_f__A----a__Liquid depth___ _________________Capacity_____ . , x_ Dispos Field: Distance from-nearest well��,r,',r]._.r._____Distance from foundation-----/AO_________Distance•to nearest lot line_ -___.___'__. Number of lines_______)'._ `fit_ _: _.______Length of each line______.1�11_._ .........Width of french.____._�-_._--__________________ T e.of filter material___��'______De Depth of filter material_,_,,.___ _Total length _.. _ Yp - p �-L�-.- --- - g ----- Seepage Pit: Distance to nearest`well_,_.__:.._______• Distance from foundation___________________Distance to nearest lot line_______________._ Number of pits----------------------Lining`?material-----------------------Size: Diameter-----------------------Depth----.----.----------------------- -MO Cesspool: Distance from nearest well_________________Distance from foundation....___________.___.Lining material----- fl ❑ Size: Diameterv. ,; z Depth ------------------------ Liquid Capacity gals. �,.,�Priv _ - Distance ffominearest well__________________ ____.._. Y =' Distance from nearest building Distance`to,.nearest,lot line--------- '._ ----------- 4' ❑ ---- - -------------- ----------------------------------- tf Remodeling and/or repairing (describe}: -------- ---••---•------------------------------- ' --------•----------------•--------------------------------------------•---------=---------------- --------- ----------------•-==----------------•--•--:------------------------------- ----------------------------------------------------- -------------------------------------------------- I V ' [ { _ _________________________________-------------------------------------------------------------------------------------___________________ __________________________„_-____.___________ ______________.__.______ --------I hereby certify_that ( have-P�e:--------------------- ---------•-...-------•----------------------•-•-----------•• ------------------ --- •-------• -------------------------------------- pared this application and that the'work will be done in accordance with San Joaquin County r ordinances, S e ws, and rules and regulations.of tate San Joaquin Local Health District. € f (Signed)..- -� -` ----------------- E �„ _ ,y_J - d/or-Contract or) ,J v By: -- ---- - --- ------------ = ---- --------------------------------------------(Title)-------- ----------------..-=...---------------- (Plot.plan, showing size of lot, location of systern in tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APP6CATiON ACCEPTED BY---- '1 --------------------------------------------------------- DATE---- ---- REVIEWEDBY-------------------------------- --- -------- --------------------- --------------------------------------------------------- DATE------------- •--------- -- BUILDINGPERMIT ISSUED---------=------------------------------------------------•-------------------------------------- DATE------------------------------------------------------ Alterations and/or recommendations:-------------- ----------------------------------------------=-------------_-------•----------•------- ----------------------------------•------------------- i. t --------------------------------------------•---------------------------•- --------------------.--------------------------------------------------------------- ------------------------------------------ -------------------- FINAL INSPEDate- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street124 Sycamore Street c 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REVISED 8-59 3M 3-163 F.P.CD.