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FOR OFFICE USE: k -------------- ------------ -------------------- 1 - U APPLICATION FOR SANITATION PERMIT Permit o. ___�........... . .. _------_-------------------- ------------- -- --------- (Complete in Duplicate.) Date Issued -7- .:f7 -63 ---------------- This This Permit Expires 1 Year From Date Issued D 2S�cSdr?� Application is hereby made to the San Joaquin ocal Health District for a permit to construct and install the work er in desc�ribedd. This application is made in cc Ii ou fy Ordinance No. 549. 3�2 J B ADDRESS A LOCATI - ----- � lRr-- -- •-- .. `--------------- --- ---- "t Owner's Name Phone------------------------------------ Address------- ------------------------ -------- ---- ------------------------------------------------------•------- Contractor's Name__. +: f"e�t !: - ---._. Phone---------------------- --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___f__ Number of bedrooms —3. Number baths __ ot size - '�'` '-"-----------•------ Water Supply: Public system ❑ Community system ❑ Private Depth t ater Table A"¢ 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© New Construction: Yes�U No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (Zn4k optic tank or cesspool permitted if public sewer is available within 200 feet.) �� Material------- ------- Septic : Distance from nearest well----- from foundatyon____._ __ _ ` ff . - No. of compartments___.___._- /Size-(��-� .I _ .1�..Liquid depth-_-_.�._....-_-----Capacity_Z _fid__ __ Disposa field: Distance from nearest well S�----_Distance from foundation___.IQ__�_____-Dist jnc ,tt nearest lot line•S"____ G 1. Number o£ lines________ �_-.__ __--_Length of each line___ �'_ SV�idtri ot�rench-- �_�3G.�f.__, � f _De th of filter material_____ff Total len th"_�� Type of filter materia__ -_ p g Seepage Pit: Distance to nearest well-----_----------------Distance from foundation--------------------Distance to nearest lot line__._---..__._____ ��f Number of Cesspool: Distance fromsnearest well--Lining mDetance from foundatonDiameter-.--Lining material ____________ ________________- ` ❑ Size: Diameter--------------------------- ----------Depth-------------------------------------- -------------Liquid Capacity-------------- F-----------galt h Privy: Distance from nearest well__.____________---------------------------------Distance from nearest building________________--_____:___-_.-,------ "-lot -___..�''=F' _ Distance to nearest lot line" Remodelingand/or repairing {describe):--------------------- ----------------------••--------------------------------------------------------------------------------------------------•- -----------_----------------------------------__________{k____________-___-__.....__._____-______________._______--------------------------__________________.___._-____-_____________--_________--________.___.____-__-__.._-__ E yr `i ____________________-----------------------------.--------------------------.------------------------------------..-_.___________-_-_-________-_-_..-__.-.____________________________________________________________._..____ r F /[ 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-regula,tions,of,the_San.Joaquin•Local-Health District. (Signed)-- 49W c 13 ----------------------------- -------------(Title)----------------------------. and/or-- --------- (Plot plan, showing size of lot, location of system in re tion.to wells, buildings, etc., can be placed on reverse side). L i _, _ ;� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....:A1 � a! _ DATE -' -?03 REVIEWEDBY--------------------------- -------:t:F------------ -----------------------------= -------------------- DATE----- ------------------------------------ -• ------------- BUILDINGPERMIT ISSUED-- ---------- ------------------------- ---------------------__:-------------------- -------------- DATE------------------------------------------------------------- Alterationsand/or recommendations---------- ----------------------- -- ------ -------------------------------------•---- ---------------------------------------•----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL-INSPECTION BY:. Date---- -------------- ---- --------------- -------------=--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycnmare Street 205 West 9th Street a Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISLO 5-59 3M 3-'63 F.P.CC.