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FOR OFFICE USE. ------------------------------------------ - ----- -- -- ---------------------------------- --------• APPLICATION FOR SANITATION PERMIT Permit No. ..... J%��.�-� - - ----------------= -- ----- (Complete in,Duplicate) Date Issued ____ --------------- This Permit Expires S 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. S49. If JOB ADDRESS AND LOCATION` - --�----------------o-------------- - ----------------------------------------------------------------•-------------- Owner's Name----- - f: �J Phone 'lr Address------....46---'3 --------- ---------� '-�--- ------ x1-------------------------- S. Contractor's Name--- _ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-1--- Number,of,bed rooms ___.`r3_.Number•of,baths :__:f__ Lot size--ft _ -Y i------------------_-- ---------- e _ .. Water Supply: Public system 91—.tommunity system ❑ Private ❑ Depth to Water TabletM ft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe &–Vardpan [] Previous Application Made: (If yes,date___________________) No 5! ' New Construction: Yes [b]�o ❑ FHA/VA: Yes ❑ No 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 fou ndalion_.�Q._____..__.Madtersal�- F'[_________. No. of compartments Size....Z--- -.------Liquid,depth------ J-----------------Capacity---- -& - Disposal Field: Distance from inearest well- -----.._Distance from foundation---f0------------Distance to nearest lot Iine_ ____- _________________Length of each lin( Number of lines___.--�_-__._ __ _--------------------.Width of trench_ __ _-___________________.___ Type of filter material_`RP_6�1?______Depth.of,filter,material___�_�_�� _.___Total length______F_ ________ __ Seepage Pit: Distance to nearer well---__----------Distance from foundation___to P..____=Distance to nearest lot line_______.-.-. [Y]� Number of pits-X-3--------Lining material--___1. 0.G_/(...Size: Diameter____3_.3-.'..______..Depth___, !________._____- 6 r O ..Cesspool: Distance from nearest well-----------------Distance from foundation_..._._____________.Lining material------------__._____._____________.__. ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid Capacity------------------------- -gals. E Privy: Distance from �earest well-------------------------------------------------Distance from nearest building.___._______________________._____.__... ❑ Distance to nearest lot line________________________ _`-------_ Remodeling and/or repairing (describe):----------- ---------- --------------------•---•------------------------------- -•-------------------------------------------------------- -------------------------------------------•--------------------------------------------------------------•---•---------------------•-------------- ----------------------------------------•---•---------------------------- -------------------------------------------------------------•-------------------------- ------•--•- -------------------------------------------••--•------------------------------------------------------ ---------------- I --------------------------------------------------------=-------------•---------------------------------------------------------------------------------------------------------------------------------- -------------- 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 reg lations the San Joaquin Local Health District. (Signed) ----- -------------------- ( + 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. 1 FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------ - ----------------------------------•------------------------ DATE------------------------------ -------------------- REVIEWEDBY------------------------- ------ --------------------------------------------------------- DATE------ ----------------•--------------------•------- BUILDINGPERMIT ISSUED------_------- -1----------------------------------------------------------------------- DATE----------------------------------------;.---------------- Alterations and/or recommendations:___� T_-�3.�-�t� --- Q--------�---- -- ---------� -- -----�----�� x � L� - -�--- - ------- ---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ------------------------ ----------- -------- ----------------------- --------- ------ -------------------------------------------------------------- --------------------------------------------------------------- 3 FINAL INSPECTION BY:.'�-- ----- e-------- °----- Date--- 1� 1 �� 61 / ------------------------------------- w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hatellon Avo. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8-59 3M 3-'63 F.P.CD.