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FO FFICE USE �� ---------------------------- ---------------- APPLICATION FOR SANITATION PERMIT Permit No. ----------- - -- -- ---------------------- --- -- - ------- (Complete in Duplicate) Date issued ___- . -._..__.-----------------___-----------------._____------ 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 0ynce No. 549. JOB ADDRESS AN CATION---p� Q ---------- -•'�_------------------------------- C-�-- ---------- Owner's Name-------- ana------- --------- --------- -- ----------- Address -._._. Phone Address---_---------------- J� --1k----------��}� ------- Contractor's � J ----------------------- ------- �� Contractor's NameyL---------------------------------------------- Phone Installation will serve: Residence ❑ Apartment House ❑ CommercialTrail rVU E] Motel E] Other ❑ Number of living units: -------- Number of bedrooms ___ ---- Number of baths______ Lot size __._ v_. ------ _________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Vo ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P?' Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if-public sewer is available within 200 feet.) Septic lank: Distance from nearest well -- -Distance from foundation__/Q---------- Mate/ial--- No. of compartments____ . a______.____Size__3_ _ __ Liquid depth--- ? ______Cap acif y__ D® Dis osal Field: Distance from nearest well _Distance from foundation__94-!__..--Distance to nearest lot line----------�_ Disyl Field: Distance from nearest well Number of lines__________ ----�- -J-----------Length of each line---!9-'-U__----------------Width of trench----2._cl-.--•---------!____--- Type of filter material__ t_L�'Q�� __Depth of filter material___ _ --__..Total length------------------------ ---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot iine_______________._ ❑ Number of pits----------------------Lining material---------- ------------Size: Diameter---------------------.-Depth---.--------------------_-------- Cesspool: Distance from nearest well-----------------Distance from foundation-------.------------Lining material__._____-_______.______._______ ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity--------------------------•-gals. Privy: Distance from nearest well------------------------------------------ g-------------------_ --- ______Distance from nearest building _ __________________ ❑ Distance to nearest lot lin --- -------------------< ------- -=------------------- �> -------------•----- ------------- Remodeling and/or repairing (describe______ _ ____ ___ = ------- ----- P - ----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------- ---------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------ I betel. certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , Sfate I s, and r es and r ulations of the San Joaquin Local Health District. (Signed) --- . . ------ - ------ --------�- -------- wrier and/or Contractor) By:----------------------------------------------- ------------------- ----�--- --------------- (Title)----�r -------------------- ..... (Plot plan, showing size of lot, location of system in relation to wells, buildings , etc., can be placed on reverse side). I FOR DEPARTM T USE ONLY pp APPLICATION ACCEPTED BY ///- .G? ------------------------- DATE-- (` ------------------------ REVIEWED BY-------------------------------- DATE_ ----- --------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE--- -------------------------- ----------------------------- Alterations and/or recommendations:---------------------------------------------------------------- --------------------------------------------------•--------------------------------•---------- ---------------------- ------------------------------------------------------------ -------------------- -------------------------•--------- ------------------------------------------------------------------------------ -----------------------------------------------•-------------------------- ------------- ------ --------- -------- -------------------------------------------------------- -------------------------- ------ ------------------------------------------ ------ --- ---------------- ---------- --- ---- --- ---------•---- ------------•-- ----------•------------------- - ---------- Date FINAL INSPECTION Y:- . -------------------- JOAQUI OCAL ALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street205 West 9th Street Stockton,California Lodi,California Manteca,California 7 Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.CD.