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FOR OFFICE USE: `------------ " ------------------------------------------------------ -- APPLICATION ICOR SANITATION PERMIT Permit Mo. .___------------------------------------------ (Complete in Duplicate) Date Issued '3 --------------------------------------------------------- This Permit Ex ires 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 her ei escrecf. This application is made in compliance with County Ordinance No. 549. ii r F E-r- '.� o JOB ADDRESS AND CATION___ a3�n.e.Q,eCcL.7 _� � d'1 - -----�g, ,,�� Owner's Name _ --------- -- ------------ _--------- Phone.-- Address ... _ .. a -------------------------------------------------------- Phone___ - Contractor.s,�Name------. y --------- p Installation will serve: Residence Apartment H se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ o Number of living units: J____ Number of bedrooms ,Number baths ---/_'_ Lot size --------- Water Supply: Public system El Community system`❑ Private Depth o Water Table -------- ft. Character of soil to a depth of 3 feet: Sand El Gravel [-] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ .,Hardpan ❑ e Previous Application Made: {If yes,date_________________4j "No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No'[-] f TYPE.OF INSTALLATION AND SPECIFICATIONS: (No sep+ic tank or cesspool.permitted'if-public-sewer is available within 200 feet.) ❑ p -------- '_Liquid de�ith - j} Capa----- -----•--------------- Distance fr S foundation--------------------Material__-__1_____" Septic Tan NoDist of compartmentance from s well Size" =' — city } Dispo /Field: Distance from nearest well_._._ _Distance from found at'on _ ------------ Distance to nearest lot line____S-1____ Number of lines_:-:-_---- ---- --Lenpgth of each line----------.-0-- -�_____-Width oftrench-._._2-_-_ _____________________ Type of filter material___ ,- De th of filter material------ Total length___.___C_Q___________________________ N Seepage Pit: Distance to nearest well__--------------------Distance from foundation ------------------- to nearest lot line__________._-___ ❑ Number of pits----------------------Lining material-------------- -, ---Size: Diameter-----------------------.Depth--_----------------------------- Ces❑sPoo : Distancenearest well Distance fromfoundation--------------------Lining material----- ---------------------------------------..- Size: Diameter--------------------------------------Depth --------- -------- ------- --------Liguid Capacit ----------------------------gals Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------- ❑ Distance to nearest lot line--------------- ------------------------------------------------------- b l Remodelingand/or repairing (describe) ----°--- ----------Q--:-------------------------•-------------------------------••----------•-------------------•-• -- ----------------------------- ------------------------------------------- --------------- -•- ------ --------- ----- - -----------------I------------------------------------------------------------------- ------ -r --------------------------------------------------------•------------ = -------------•---------------------•----------------------------------------------- ------ - g --------------------------------q------------------------------- ---------------------------------------------- --------------------------- -- I hereby certify that I have prepared +his application and that +he 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)By:. r er- - k- ---------- ---------- wa or Contractor) - �---= =- (Title)------------------ --------------------------- - -------- (Plot ---- I (Plot plan, showing size of lot,.loca+ion of system in relat to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------- ----------------------------------- ---------------------------------------- DATE------------------------------ REVIEWED ------ ------------------REVIEWED BY --------------- DATE----------------------------- a BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------- - ------------ -------------- Alterations and/or recommendations: -- ---------------------------------------•--- -------- --------------------------------------------•--•--------- ------ --------------- Z FINAL INSPECTION BY:-.-. ! Date...... 7 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 8-54 3M 3-'63 F.F.CO. ry _y