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FO OFFICE USE: F �" ----------------- ------------------------------ ---- -----------16, APPLICATION FOR SANITATION PERMIT Permit No. ..� ._.3._ ..S f w ------------------------- - ---------------- {Complete in Duplicate) --------------- --- This Permit Expires 1 Year From Date Issued 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_ Count Ordinance No. 49. ppss , JOB ADDRESS AND LOCATION�,/IJ__-_ .__ _ _- i l�i'l�- Owner's Name______ } Phone -------- Address------ ` Contractor's Name - --------------------------- ----------- -- Phone----------------------------------- Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l__- Number of bedrooms _�� -_ Number of baths _Z_ Lot size Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tables%1Tt/ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er-THardpan ❑ ' Previous Application Made: (If yes,date-.._-__---________) No 91---New Construction: Yes ❑ No FHA/VA: Yes ❑ No 9— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se,Ptic Tank: Distance from nearest well_________________Distance from foundation--------------------Material _--.._________._______- . f Na. of eampartments Size- ----------------------- -------Liquid depth--------------------------Capacity----------------------- Disposal Feld: Distance from nearest well___-- 'rDistance from foundation._` _F----Distance to nearest lot line----t�/_____ _--____._ _Length of each line__-- _-___.__ .-_ Number of lines---------�-----�.___ ��_ Width of trench-�----------------------------- L -- Type of filter material G/-Depth of filter material__-l�`f'-____Total length--"— _`_____________ 7 --------•---- j � Seepage Pit: Distance to nearest well---_"~------Distance frr foyPdation____ 1_/ _Distance to nearest lot line- Number i e- number of pits------`_------------Lining material_- -_..G__-__-Size: Diameter_ _______Depth- _--,0/� -_. Cesspool: Distance from nearest well-------------__Distance from foundation------------------- Lining material----------------------_-______-------- 0�0 ❑ Size: Diameter--------------------------- ----------Depth---------------------------------- - -__----------Liquid Capacity----------------- ---------gals. Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building ❑ Distance to nearest lot line----- ------------------------ Remodeling -------------------- - Remodelin9 and/or repairing (describe):----------� �!. � ------------------------------------ ---------------------- -------------------------------------- }V'�r .. ----------------------•--------------------------------------------------------------------------------------------------- 3 - ----------------------------------- ------------------------------------------------------------------------•-------------------------------------------------------------------•--------------------------- ---- ------ 1 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 les and regulations of the San Joaquin Local Health District. 1 (Signed)------------------ ---- --------- -- - - ` -- - ----------- ---- - -- - -- -= ----- ----------------------------- -------rtQjxwx=nrJ/or Contractor) By:---------------------------------------------- - /l�i� [Title)-.-- ------------------------------------ -- (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- DATE 'f REVIEWED BY------------------------------------- - DATE ---------- --------------------> -- ------------------------------------------------- ----------------------------------------- BUILDING PERMIT ISSUEb -------------------------------------------------------------------------- - ------ DA•TE.------------------- Alterations and/or recommendations:_ ------------••- -------- ----------•-•----------------------------- ------------------------------------ ---------------------------------- ---------------------------------------------•---------------------------- ------------------------------ FINAL INSPECTION BY: - C,r- -----------------------------------------------cDate--------4-- SAN -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California C5 9 REVISED B-59 3M 3-'63 F.P.CD.