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FOR OFFICE USE:------------------------------------------------ APPLICATION FOIL SANITATION PERMIT Permit No. ...... ..... ------------- - -------- (Complete in Duplicate) Date Issued ___1� 3. _�3 ------------------------------------.--------------------- 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 AND LO TION-- - ---- �j Phone ----I.. Owner's Name----- ------------------------ ------- ------------- = n Address-....... `. = 4 --x ------------------_--------------------------------` ---------------- ------ Contractor's Name--- � ------ Phone----------------- Installation will serve:l+Residence X Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ 'Ofher ❑ Number of living units:-____ Number of bedrooms . '- Number of..baths Lot size --------------- - ___----------------------_-------- __ Water SuPPIY� Public's stem . CommunitY system ❑ Private � DePpth to Water Table /--�ft. � Character of soil to a.depth of 3 feet: Sand E] Gravel El Sandy Loam, Clay Loam ❑ .,Clay E] Adobe, Hardpan [ p� a Previous Application Made: (If yes,date-......_...-------,_) No New Consfruction: Yes-] No ❑ FHA/VA: Yes ❑ No LLk TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well---:-------------Distance from foundation_-_-_:_______-____.Materiai_____.._____________.._---_-..._-_.______._____- ❑ No. of compartments-.-.,,,.,--------------------Size---------------------I----------Liquid depth-------------------------Capacity------------------- • DisposalId: Distance from nearest well.::, �_�_Distance from foundation---/.52----------Distance to nearest lot line----- ___.__ ii E-11 Number of lines_____'-___J____________________Length of each line_____l_0'--o-��_-_---.Width of trench._____- _-__. ± ______- Type of filter materiat.�/i�-----------Depth of filter.material----AX.____ Total length-------/-0----------------____________ Seepage Pit: : Distance to nearest well_____ _______________Distance from foundation------------------_Distance to nearest lot ' - Diameter,.,_,,-_ , line__.__-_________ [ ),,, Number of pits------- material----------------- �Size: --,----.----------.De th------------_------------------- Cesspool: '~ Distance from nearest well-----------------Distance from foundation---------------------Lining material-,_.___--___-____._ ❑ Size: Diameter--------------------------------- ----Depth----------- --------------------- - ---------------Liquid; Capacify_._.-----------------------gal Privy: _ Distance from nearest well--------------------------------------------------Distance from nearest bui#ding-__------------------------- _.___. ❑ Distance to nearest lot line---------------------------------------------- ----------------------------------------------------------------------------------------- -- i Remodeling and/or repairing [describe):__. �-t.� = 1 ----- - --ter' } -'- -- ----------------------------- -------------- ---------- --------------------- - ---------------- _,. .x1; --------------------------------------------------•-------------- ----------------- ----------- ----------------------- ------------------------------------------------I--------------------------------------------------------------------- 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 the San Joaquin Local Health District. - - - ---- -- --- f_ _ ----- or Contract ------- ------ --------------------------- -------------{Tit�- - - ---------...- ----- ---- - - - ------------------- (Plot ------ - ------- (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - ------- --------------------------------------------------- DATE--/,t-_-' a^G ---------------------- REVIEWEDBY--------- ------------------------------------------- ------ DATE------------------------------ --- _---------------------- BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE.----- ---------------------- --_------_--------_------ ---- Alterationsand/or recommendations-------------------------------------------- -------------•---------------------------------------------------------------------- ----------------------------- I t. -------------------------------------•------------------- ---------•- --- --------------------------------------- -------------------------- -------------------- - FINALINSPECTION BY--- --------------- -------------------------- Date_-— --- -�-~--�-------- ----- ----------------------------- 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 13-SO 3M 3-'63 r-Po-CC.