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R FFICE USE- /----------- --------- -----------.- _____ ________________._____.__-.__-.._--T ---------- APPLICATION FOR SANITATION PERMIT Permit No. __ �.3... ... - --- --------------------- ----- (Complete in Duplicate) Date Issued --------..............=------------------------------. This Permit Expires 1 Year From Date Issued . ----- -- -------- -- i 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______ �'�-_'° : V1W --- --- ------•----------- •---............. Owner's Namesa.—tre Phone ------------------------------------ Address-------.......3112-2-4 ------------•---- ;6 Contractor's Name------ - -----° ----� ------------------------------------------ Phone----------------------------------- Installation will serve: Residence ®�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms Number of baths ___T___ Lot size ___________________.___.-____--____ Water Supply: Public system ❑'—Community system ❑ Private ❑ Depth to Water Table - _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe n4 Hardpan ❑ Previous Application Made: (If yes,date____________________) No New Construction: Yes ❑ No R? FHA/VA, Yes ❑ No E' 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 foundation_/9--_____ ____.Material__ _`_ __/-__ _______________ { No. of compartments_.Z.______ r____.____--Size---3�_.��'`--�--_-:_--Liquid depth----�-----------------Capauty_kC3p__,�_j&� Disposal Field: Distance from nearest well-________________Distance from foundation--------------------Distance to nearest lot line---------------- ❑ Number of lines-----------------------------------Length of each line------------_----------------.Width of trench.------------------. -- -- - --- Type of filter material-------------------------Depth of filter material-- --------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line_____________.__ ❑ Number of pits-------'--------------Lining material-----------------------Size: Diameter----------------- -----Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- Size: --._--- _____-_-.____-_.__-______- Size: Diameter----------`-----------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-----___---------------- ___________________i___Distance from nearest buiiding------------------------------------------ ❑ Distance to nearest lot line--- - ------------------------------------------------------------------=------------------------------------------------------------------- O Remodeling and/or repairing (describe) ! .. Q -----------------•-------------------------------------------------------- -------------------------------------------------------------•-------•---------------------------------------------------------------------------------------- -----------------------------------------------------------c� --------------•-----•--------------------------------------------•----------------------------••------------•-•-------•----••----------------------------------------•-------•------•--------•-------------------------------- ----------------------------------------------------------•--------- -------------------- --------- -----------------------------------------------•----- -------------•--------------------------------------- - -- - - 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. ____._________________Ownerand or Contractor (� ( / ) (Signed�-------------------------------- y r}. 6tw-_ ____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-----C- --SediL,5 ------------------------------------------------------- DATE-- 5----- ' ------------- --------------- REVIEWED BY ---------------- ------------ ------------------------------------.. DATE---------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE--------------------I---------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------•---•------------------------------------- ----------..----..-..--------------Y---•-----•------------- ------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------- ------------------------------ FINAL INSPECTION BY:.... s ' -------------------------------------- Date-------5,-.c_-1'._Lvov--•------------- ----'------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-•63 F.P.CD.