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. r FOR O�I E U,SE. -- `' = Permit No. 5 3. - � y APPLICATION FOR SANITATION PERMIT rl----�--•-- ----- � l - A-------- --------- ------- (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 Ordinan No. 549. JOB ADDRESS AND LOCATION--- r------ 'Z 3 = -------------------•-•--•--------------------------•-------------••--••------------------••------------ Owner's Name---------J-------- ---------------- -------- Phone....-•--------------••-•-••-------•- Address---------•--------- Z-3--7- ---------------------- ----- ontractor's Name--------- �_ � Phoria Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: __1_____ Number of bedrooms .5___ Number of baths J--- Lot size _a_x- 7 �.--------------------------- Water Supply: Public system R3--Community system ❑ Private ❑ Dept.h to Water Table. ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe El ardpan ❑ Previous Application Made: (If yes;date---------------------) No gai New.,Construction: Yes �o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well^�-----Distance from foundation-_h -------------M ______________________________________ [► No. of compartments-------`Z--------------Size--------- �---Liquid deph------�'Z--------------Capacity--- a Disposal Fi_e4d: Distance from nearest well -___.Distance from foundation_._I_Q__�- ___-Distance to nearest lot line rrY- _. Number of lines-------------Q--------- ----Length of each line------------_7.�� -------Width of trench----.- _5'4---------------.__- Type of filter'material__ a- - _______Depth of filter mate rial____$_/------------- length----aw!�____------____-------------- �1 Seepage Pit: Dis#ante to neares# well_'2 _-______Distant m fo ndation_.�°_ ._-___.Distance to nearest lot lineC�______.._ 9 Number of pits...... -----------Lining material_ --_Size: Diameter___ - -.-___Dept h------ ........._------ r-, Cesspool: Distance from nearest well________________Distance from foundation---.---------------.Lining material____-___._______________________-__-- � F1 Size: Diameter--------------------------------------Depth.-- ------------------------------------------------Liquid Capacity------------------------ Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------.,_____- . ❑ Distance to nearest lot line-------------------------- ----------------- -------•--------••••------------------•-----------•-----------------------•----------------- Remodeling and/or repairing (descrihe):---------------------------------------------- ---------------------------11---------------------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 rules a re cations of the San Joaquin Local Health District. (Signed) -------------- ------ - ----- ----------------------------------------------------------------------------------{Owner and/or Contractor) " By:.... , --- --------=-- -----------------------------------------------------------•----(Title)-----=-=------------------------------- - ---------------- (Plot plan, showing size of�lo , lacation of system in relation to wells, buildings, etc., can be placed on reverse side). � E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - /-------------------- DATE----- 4 Z�" f-_----------------- I REVIEWEDBY-------------------------------------------------------------------------------------- ---- ----- ----------------• DATE-----------------------------------------------•----------- x BUILDING PERMIT ISSUED----------------------------------------------------•---------- -------------------------------- DATE-----------•--•--------- .. Alterations and/or recommend ations:___ .�_ -_?-_�lr_�:.._�.�r1 .�_ _ ------ -• ` � ! ?- -.�-- - -------------------------------- FINAL, INSPECTION BY.::___-- -- _- - --..--l�i.,.....,�,-----•--- Date-- _.- ;s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street= 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES-9 REVI9E0 a•69 F,P.CO.215 6-60 " -m