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F ONCE USE: ----------- --------- µ --- -�-�. --��- ---------------- -_ __ APPLICATION FOR SANITATION PERMIT Permit No. .. ----- ------------------------------ -------------------- (Complete in Duplicate) ..__-__._--___.--- This Permit Expires 1 Year From Date Issued Date Issued ._Z / .__ � 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, o. 54.9 JOB ADDRESS AND OCATIOc._�. �11F4_ &--------------------------------------------------------------------------------------------------s Owner's Name ' ----•-•---- • •----•--------•----------------------------------------------------------------- Phone Address ••-------•41 --- ---- ------t--- - Contractor's Name v -P--h-o---n-e--------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ i Number of living units: .-/- Number of bedrooms _,t Number of baths _./--- Lot sizet0T_X_/�______________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 4I 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............:.......I No Z? New Construction: Yes ❑ No [4 1 HA/VA: Yes ❑ No @q.— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sgptic -Tank:. Distance from nearest well_________________Distance from foundation--------------------Material--------------------._.______________._----____. j&�IkjE tf No. of compartments----------------- --------Size--------------------------------Liquid depth---------------- ---------Capacity---•------------------- Disposal Fie;& Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_______--____-___ 06 Number of lines----------------------------------Length of each line---------- ---------- ---Width of trench------------- -- W Type of filter material-----------------_-------Depth of filter material-----------------------Total length------------------------------------------ V) See age Pit:— Distance to nearest well----_" '_______Distance from fou dation__' o_!____.Disf nce to nearest lot line'� �-.- � je 00 Number of pits____ / _ ____Lining material _Size: Diameter_ .___Depth. �.�_,�!��' N Ce�o40' Distance from nearest well-----------------Distance from foundation--------------------Lining material__._-___________.__.________-_ ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity---------------------------gals. ` n Privy: Distance from nearest well _________________________________-----_--------Distance from nearest building......._-,__-__----______________..___.._. V„(, ❑ Distance to nearest lot line ------------------------------------------------------------------------- i1 Remodeling and/or repairing (describe)-------------- ..�� = -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------•----------------------------------------------- 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 qmd regulations of t San Joaquin Local Health District. --- --- ----- ------- -- -------------------- -------------------- -- �r Contractor) (Signed)-•----------•---------- By:---------------------•--------•-------------• - '------------- Title (Plot plan, showing size of lot, location of system in r tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ---- &_�------------------------------------------------------- DATE--------4!��X:'?.::6_ - CK REVIEWEDBY--------------------------------------------- --------- --- ---------------------------------------------------------------- DATE--------- ------------------------------------------------ BUILDING PERMIT ISSUED----------------------•-------- ------------------- -- DATE--------------------------------------------- --- 7 and/or recom datio ---- -------------------- s �� -- WP- ----- - - - --- ------------------------------ --------------------------------------------I---------------------------------------------------------------------------------•---•--------------- ----------- ----------------------------- ----------------------------------------------------------------------•--------- --------------------------------------------------- -------------- -------- -------------------------------------------------------- -------- FINAL INSPECTION BY:--------- ��..Gll'-------------------------------- Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:titan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r:s 9 REVISED B-59 3M 3-'63 F.P.CD.