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IFOROFFICE USE:�u I - 3_-1.5----.-----------------------3:--.--_-.--- 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 Ordinance No. 549. JOB ADDRESS AND LOCATION... ----- _ -C - �� --------------------------- ------------------------_-------------_--------------------------- Owner's Name_-__)--- ___ O Q�YL-1 ------•----•------------------- ----------------------------- -------------- Phone__.... ------------------------ Address-.--.--------- - - Phone__.-..__......------•--•-------- Address-•------------------- - Contractor's Name___-_____ __ Phone----------------------------------- Installation ----------------------------------------------------------------------------- --------- ----•-------------------•--- --------------------• 0.1 ---- ------• -----�----- -•--------------------------------------------------------------------------- Installation will serve: Residence ❑I/Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: j----- Number of bedrooms ___,3_ Number of baths -- Lot size _-. .9_s�k Z /,,,.,�� - ------------- --- ------_------------- Water Supply: Public system E��ommunity system ❑ Private ❑ Depth to Water Table __G_-Y-ft_ r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe ardpan ❑ Previous Application Made' (If yes,date____________________) No New Construction: Yes Eq-'I�o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearest well________________Distance from foundation___lv_-I.____-.M teria# _ - .._._____ yy� c� ---. No- of compartments_.__ ----------------Size__2o,�'_ �__?�%------Liquid depth- - ---------------Capacity-eQ - Disposal Field: Distance from nearest well-_—__-._____Distance from foundation___--__-__--_-Distance to nearest lot line__.-�___ Number of lines_______ __- Length of each line______ r _-Width F !n g dth of trench.-_ _¢. --- ------------- Type of filter materia�,�_C,_A�__Depth of filter material-_-_lg"__ _________Total length____/Cf_________-___________________- r See a e Pit Distance to nearest well------ ________Distance fr m foundation________ v_____-Distance to nearest lot line _____.._ O ' p Number of pits.__.-----r .___Lining material _ Size: Diameter._._-7-.-__. ___Depth-_-�I_""�-_______ 1� Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material--------------.________-____________ ❑ Size: Diameter--------------------------------------Depth--- '----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest weli:A---------------------------------------------Distance from nearest building-------------------------------- 0 ❑ Distance to nearest lot li'n'e.f-----------------------------------------------------------------------------------------------------------------------------------------l � I ` V ' Remodelingand/or repairing (describe):_-- -------- ----------------------------------------------------••------------------- -------------------------------•------------------------ ----------------------------------------------------------------------------1---------------------------------------------------------------------------------------- -------------------••---------------------- -- ---- ---------- ------------- -----------------------------------------------------------------------•---------------------------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 rule 4and/egulations of thle�San Joaquin Local Health District. (Signed) ----"-- --------------------------- --- ------------------------------------------(G*ner-andt-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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- (.__- � - ----- -----------------------------------------•---------------------- DATE "fes d� �' REVIEWEDBY---------------------------------------------rl--- ---------- ---------------------------------------------------------------- DATE----------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE----------___---------------------------------- Alterations and/or recom en at'ons:- -____-_-_—.______ ._ . --- -------- ---------------------------------------------- ---------------------------------------------------------------- ---------------------------------------- -------------------------------------- -------------------------------------------------------•--------------•-------------------------------•-------------•-----•------------------- r---------------------------------- FINAL INSPECTION BY.._._`=__` _. f Date-_'- H -------- -----r AQUIN LOCAL HEALTH DISTRI T 1601 E.Hazolton Ave. ak Street 124 Sycamore Street205 West 9th Street Stockton,California fornia Manteca,California Tracy,California ES 9 REVISED B-59 3M 3--63 r.p.CD,