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FOR OFFICE USE: t - -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT x Permit No. _._ZLI- -- ----------------------------- ------------------------ (Complete in Duplicate) Date Issued -------,_-��--__----T ________________.__.--_--- -------------------------- 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. 49. JOB ADDRESS AND OCATION ---------�_�_-__ _____. /j -------------•-_- ------------• ------------------------------------------------ Owner's Name (el��-- . ---••----------•---------------------------- --------------------- -- ---- ----- Phone------------------------- Address------------R dE__---•- -•------- ------------------------------------- ..------------ Contractor's Name----------- - - - -----r •--•---•----------------------------------------- - Phone. Installation will serve: Residence �Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Ar Number of living units. _/__- Number of bedroom-_- Number of baths l___ Lot size 4�_X 1 �____ Water Supply: Public system R17'�__ommunify system ❑ Private ❑ Depth to Water Table4ir4l . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe e--gardpan ❑ Previous Application Made: (If yes,date-----__..____...__-} No X?' New Construction: Yes ❑ No FHA/VA: Yes ❑ No?2�— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Z'Wttv ic,Ta k: Distance from nearest well_________________Distance from foundation--------------------Material______..____._______.:..______-_____.._-____-___. No. of compartments------------------- ----Size--------------------------------Liquid depth--------------------------Capacity------------- Disposal Field: Distance from nearest well_____"'_-_Distance from foundat __Distance to nearest lot line___ `--____ C � 4 Number of lines---------/--_�_____----------Length of each ---------------.Width oftrench_.g_..-r__-_---_-___..._______ Type of filter material_�g„/ Depth of filter material___�,�_l____Total length___ __ ___________ V� �. _ Seepage Pit: Distance to nearest>well________—�'___-_-Dista o dation__s.& --- ___Distance to nearest lot line-tO Number of pifs...._!______________Lining maferi ____ Size: Diameter__JW-J`__.___Depth.Xt�_r?._____-_-___.-.__._ Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-_._____.__________.________________ ❑ Size: Diameter--------------------------------------Depth-------------------------------------------_-_--Liquid Capacity----------------------------gals. Privy: Distance from nearest well..-------------------------------------------___Distance from nearest building________________________________________. ❑ Distance to nearest lot line-------------- ---------------------------------•--•----------------------------------------------- ----------- Remodeling and/or repairing (describe)------- ------19""dG - 9 -------------------- --------••------------------------------------------------------•----------------------- - ------r'--__-____-._------------------------------------------------------------------------- ---------- ----------------------------------------•---------•--•---------------------------------------------------------------------------------------------------------------------------------- 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 regulations of the San Joaquin Local Health District. Ad- (Signed)------- -- --------------- ---------------------------------(Owner and/or Contracfor) By:----------------------------------------------------------------------- uit-�szz�`---------•---------(Title) ,�j -_ (Plot plan, showing size of lot, location of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- - '------------------------------------------------------------ DATE--------4-/..2- ---------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------- -------------- ---------- ---------------- BUILDINGPERMIT ISSUED----------------------------------------------- ----------------------------------- - DATE------------------------- `! y ----------------- --- ------ti it I:at' and orrimoepO"ons•------------------- ------------- _.______ • �_ j ^ O 1 -1 -- ------------------------------------------------------ ----------------------- ----•-----------•- ----------------------------------------------------------- ---------------------------------------------------- FINAL INSPECTION BY--- ------------------I_ Date-------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8-59 3M 3-163 F.P.CD.