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FOR OFFICE USE: 0 -- / 711 C - ----------------------- ------------------------------- - APPLICATION FOR SANITATION PERMIT Permit Na. ............. .. ... -------------- --------------------------------------- (Complete in Duplicate) y 3� ` From Date Issued �� Date Issued ---- -------- --- -- 0,03--r-tla -� A lication Is herebymade to the San Joaquin Permit Expires 1 Year Pe ' Local Health District fora.t,77-7 VA mit to construct;and install the work herein descrl ed. Thisapplicationis mde in compliance with County Ordinance No:54 f 0_ _� JOB ADDRESS ANP LOCATION---- - - ---- � � e.�`� Owner's Name------- __---' - � . - ---------------------- Phone Address------------------ ---------••----- ---- ..------------------- - -----------------•------------ ----------------------- -------------------------------- Contractor's --------•--•-------------• -JContractor's Name-- - --------------- Phone-one- Installation will will serve: Residence [Apartment House ❑ Commercial ❑ Trailer,Court ❑ Motel ❑ Other ❑ __ Number of bedrooms 3_ Number of baths /-_-. Lot size ___-! __ .sG:IP -----------_---------- Number of living units: __I Water Supply: Public system E] Community system E] Private�15epth to Water Table 4.� 1 Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] 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: _ 1 r {No septic tank or cesspool permitted if public sewer is available within-200 fee+.) ' Ic T nk: Istance from nearest well-----------------Distance from foundation-------11-----------Materiai______________________________-_____________- No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity------ --------------- Distance from near st well___t_a_f1__1_Distance from foundation----- _ ---.Distance to nearest lot line_._-__ Number of lines_--. ---- --_Length of each line__�7-d- ...........Width of trench__ �______________-__ n — of filter material__ De th of filter material------- _,�____---- Total length ----------------- Type l_ P eepage Pit: Distance to nearest well__ �4- ___Distance from foundation___1s-_____--- Distance��o nearest lot line_ i Number of Its___tt Linin material__ _,V_C4�_----Size: Diameter______ .- Depth----- --___�___._ P k------------ g R Cesspool: Distance from nearest well-----------------Distance from foundation-------I!-----------.Lining material__._..._______________.__.__.______ Size: Diameter--------------------------------------De th--------------------------------- - - -'I----------Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------.____--- ❑ Distance to nearest lot line-----------------------------------------------•----------------- ------------------------------------------------------------- --------- L T Remodeling and/or repairing (describe):--_-- -- ---- -----1-----' - � , - -= P- --- ------------------- ----------------------------------------------------------------------------------------------------------------•----------------------- �- ------------------ --- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Hea District. _ t {Signed} � r r Con#ractor) By----------------------------- -------- _{Title}- ------------ - T Y �! (Plot plan, showing size of lot, location of system in relation wells, buildlings, c., cn be placed on reverse side}. FOR DEPARTMENT USE PNLY APPLICATION ACCEPTED BY --------------------------------------------------- - -- -14-7�--- DATE-------- 7----------------------------- REVIEWEDBY------------------------------------- ----- - -----------I------------------------�.'... DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------ ---------- ------ -------------------------------------------------------`-I. DATE------------------------------------------------------------- ih Alterationsand/or recommendations:------- ---------------------------------------------------- --------------------='----------•--------------•-----•-•----•--•-------------------------------- --------------------- ---------•-------------------------------------------•---------------------------- -----------••--------------------------- ----------------------------- --------------------•----------------------•- i ---------------------------- ---------------------------------------------- ---- -----------------------------..--------------------------'---------•-1--------------------------------------------------------------- 4 ---------------------------------------------------------------- ----------- ------------ ------------------------------• --------------------• -------------------------- Q---------------------------------------•-- ----•--- 1. - --- --------- ------------ ------- ----------------------------- - ----------------------------------------------------------------- II FINAL INSPECTION BY:...r///" ------ ---------------------------- Date_l' -• - f G� - SAN JOAQUIN LOCAL HEALTH DISTRICT 116011.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California 'f ES 9 REVISED B-59 3M 3-'63 F.P.CD. 4 I. 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