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FOR OFFICFVUSEP -� APPLICATION FOR SANITATION PERMIT Permit No. ...... �-CI ------- --------- ---------- ---------------------------- --- -------------------------- (Complete in Duplicate). ----- ---- -------- ----- -- This Permit Ex ices 1 Year From bate Issued - Date Issued -_ :"_ :�_"--"3 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 N 549. Zvi JOB ADDRESS ANP LOCATIO a' 1.Q Owner's Name"-_ --------- .------------------------------ ._" --- -------------- ------------------------------------------------ -- --------- Phone----•---------------------- ----- -- -- ------- -• -- ------- . ----- 19 Contractor's Name --_ - ------------------------ ------ -- ---- ----------------------- __ Installation will serve: Residence UR Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other Number of living units: --I--- Number of bedrooms 1�_Z-_ Number of baths _ Lot size ----- __ E] Water Supply: Publics stem `� y ❑ Community system ❑ Private [y-15to Water Table .blD_ ft. Character of soil to a depth of 3 feet: ` Sand p Gravel ❑ Sandy Loam ❑ ClayLoam ❑ Clay [] Adobe , 0--=lardpan ❑ Previous Application Made: (If yes,date--------- ----------) No New Construction:- Yes ❑ No K-__'FHA/VA: Yes ❑ No Rj-' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publicseweris available within 200 feet.) r r Septic Tank: distance from nearest well__a5-Q-_ -__Distance from foundation_10"""__-""-_.Material__ --"-_--_-"-_-""-_----------- ------------ No. of compartments---------- ------------Size--"----- sS` -�---Liquid depth-----�- ------Capacity-.,_�Oo_ •� Dis osa Field: Distance from nearest ell.-�------Distance from foundation_/_�?-__-----_ Dis`taric ,toy riearest lot p Number of lines----____- ------------""-"--Len th of death line - ic7f}I r ch--- -- ----------------- Type of filter material- _6_C-A--_-_-" r ��w w �_ � Depth of matercal__f f�_`---- lengt}�.------�p"'--.+-=------------------ Seepag i#: Distance to nearest well-1 -----------Distance from foundation_/CX_44-'---.Distance to 'nearest lot line---0--_/___ `• UV Number of pits-------f-------------Linin material____ $ize: Diameter_---------- Deptn.---- -f_ Cesspool: Distance from nearest well----.---------..-Distance from found'ation--------------------Lining material----- ------------------1------:. ❑ Size: Diameter------ ------------------------------Depth--------------------- ' Liquid Capacity -------gals. !y Privy: Distance from nearest well-----------"---------------- Distance from nearest buildin `V + ❑ Distance to nearest lot line.- g-------------------------- -----------�- �`��-e - ------------- - , Remodeling and/or repairing (describe):-------- --------- -------------------- ---------------------"-----------------------•------------------•-----•-----•--------------------------•--------- - ------------------------ --------------------------•------------•--------------- ------------ -------•----------------------------•-----------------------------------------••-------------------------------------- ------------------------ -----------------------------------------------------•----•------------------------------------------------------------------------------------------------------------------------------- --- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of;�/haaquin Local Health District. (Signed) ------(Owner and/or Contractor) By:-------------------------------- -----------• ------ Title -------------------------------------- - __---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). z FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C_---A--tW 3t -_---_-------- L 3 ------------------------------------ DATE--- - ----•- REVIEWED BY - --------------------- DATE-- BUILDING PERMIT ISSUED--------------••------------------------------------------ --- ------------- E A! erations and/or recommendations:-__ c S$ ------------------------ - -------- --------- ------------ FINAL INSPECTION BY:---------- -------------------- �__ -� r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi, California Manteca,California Tracy,California i ES 9 REVISED 8-59 3M 3-'63 F.p,Co.