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FOR OFFICE USE; - --------------------------------------------------- ---- APPLICATION FOR SANITATION PERMIT Permit No. ._...L .7• ----- -------------------------------------------- ------ (Complete in Duplicate) Date {sued ---3 a ------------------------------------------------- ----- 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. i " ? D t 3--o zed--s f- ---------- JOB ADDRESS AND LOCATION..��+ --- ---�-- `- a_ ................. "dr'`�------- ----------- - -•--- Owner's Name ° �'-- -- ------------•-•-• --��------``•---------- Phone Address------------_------- ---vv----=------------------------------------- °�- �-' �' c - -----��------------------------------••--------------•----------•------------- Contractor's Name--.G..= q -- D'`l�t•= Phone Installation will serve: Residence [p Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _13___ Number of baths ___ Lot size _--___________________________ Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table _c ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.f] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ I Previous Application Made: llf yes,date-----------_--------1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ s 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---------------- ------ rl *p , Field: Distance from nearest well_+��........_Distance from foundation__3Af---------Distance to nearest lot line--- ___.-_____ ❑ Number of lines----.-______________________A_Length of each line___J_0-4-_______.___._._.Width of trench...�nf/ -----------._.____.____ Type of filter material 114&,_k_m!k_Depth of filter material____.�_�__........Total length--./--- p Seepage Pit: Distance to nearest well__.__________________Distance from foundation---.----------------Distance to nearest lot line--------------1c;F ❑ Number of pits----------------------Lining material----------.------------Size: Diameter-----------------------Depth----------------- ------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________---_______-_____. ❑ Size: Diamefer----- --------------------------------Depth------ ------- ------------ ------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well _______-----------------------------------------Distance from nearest building-------------------------------------- Distanceto nearest lot line---------------------------------- - ------------------------------------------------------------------------------------------------------ Remodeling and/or repairing {describe) d .. -�^Yt/.. � ',,'r""_' s ----•----------- --•----------------------------------------------------- , -------------------------------------•-------------•----------------------------------------------------------------------------------------------•--- l ------------- ---------------------------------------------------------------------------------------------••---------------------------------------------------------------------------•----------------------------------- ------...:--------------------------- -----------------•---------------•--------------------------------------••---------------------------------------------------------------------------------------------------------- I hereby certify that 1 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. (Signed- .- (Owner and/or Contractor) i` By: ------------------- = {Title) (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ? ------ ----------------------------------------------- DATE--3-_ ----------------------------- REVIEWEDBY------------------------------- ------------------- ---------------------- - --------------------------------- ------ DATE------ ------ BUILDINGPERMIT ISSUED---------------- ------------------------------------------------------------------------------------ DATE------- --------•-------------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------•-------------------•-------------------------------------------------------------------------- ----------------------------------------------- ----------------------•----------------------- ----------------------------------------------------------•-------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- - ----------------- ---------------------------------- , FINAL INSPECTION BY: -------------•---- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxallon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street I Stockton,California Lodi,California Manteca,California Tracy,California ES.9 REVISED B-59 3M 3-'63 F.F.00.