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FOR OFFICE USE: , -------------------- 5` r. ...---- 1 r APPLICATION FOR SANITATION PERMIT Permit No. C_�.3--_..... . - -------------------------------------------------------- (Complete in Duplicate) Date Issued #2,714y _________ ------____________________.____..._ --- 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 LOCATION----- .. `�--------- K-------- '?�C '--------••------------------- ----r Kr =q-- ------�------------------------------- Owner's NameL_A-------------* ------ ---1771, ---------------------------- ------ Phone.3`?~_s __7-1 Address----- ------_---------- -------------------------------------------------------------------------------------------------------------------------------------------------------- �------------------------------------•----------------------------------------------------------•--------------------•--------------��------------- Contractor's Name------ f! G �� = S,.z- �`�-`' `_--------------------------- � -•---------------- ----------------------- Phone.�,�� 7-------- t Installation will serve: Residence P6 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1____ Number of bedrooms -'"Afn- Number of baths _C____ Lot size ____--- 1__�C___�-� Z---�---•-------------- Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date____________________) No X New Construction: Yes ❑ No�a FHA/VA: Yes ❑ No,M TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material-------------------.___-__________._______----. ❑ No. of compartments------------- -----------Size-----._------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest Distance from foundation-----LQ..........Distance to nearest lot line___y __,______ Number of lines-_________I----------------------Length of each line_______-�r-T<2.`______._-Width of trench---------- --.___.____-__ Type of filter material___`, :' ,fS. ,_-_Depth of filter material ____% - --Total length______________________ _`_______- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------.-----------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-----.--------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-----.------------------------------- S ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_____ ------------------------------------------Distance from nearest building----------------------------------.-_..._.� ❑ Distance to nearest lot line._-_-_--- --------.-�------1---'-I-------------_-c----,-t-r--k-•.----I.-.--r---.-C-.----•------ -----------------------------.--c-----------------.-.-_-,---------- �-L--- r f� Remo lin9 and/or repa� ing (describe):_______ _ rJ --- -------------------------------------------- -------------•-------- ------- -- ------------------------- -- ---- - -----------------------------------------------------------------------. ---- ------ 1 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. ___________ �� - - {Owner and/or Contractor) - ------ --------------------------- (Signed) --------------------------------------- By:---•-----------��1:__-------r H- `'� ' s� --�.------------ LTi+le] - - - -------------- (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------ . - ---------------------;------------------------------------------- DATE---- Z --------------------•------ REVIEWEDBY------------------------------ -------------------------------------------- ------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------- ------------------------------------------ ------ DATE------------------------------------------------------------- Alterationsand/or recommendations:----------------- -------------------------------- --------------------------------------------------------------------------•------------------------------- -----•--------•--•----------------------------------------- --------------------------------------------------------- ------------------------------------•--------------------------------- -----------------------------.... FINAL INSPECTION BY:....-Q1.+.... ------------------- ----------- Date.------ ' Z --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 31A 3-'r.3 F.P.CD.