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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: .-_./.. '� � - ------------ --------- ----------------------- (Complete in Duplicate) --------- - ------------------ --- - Date issued -- -------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application Is made in compliance with County Ordinance No. S49 1(20-7/ JOB ADDRESS AN LOCATION- ---- -- 1 '" .. -- -Q c Owner's Name - 61 - --- Phone. c � Address ---------- '- ------ R -------------- ----- Contractor's Name------- --- ---- -- - ---- -- --------- ---------------- Phone--------------------------- -----•- Installation will serve: Residence °[�lApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othe ❑ --- umber o baths -_? Lot size --- - ------- ------------ -------------------- 1 Number of living units: /--- Number of bedrooms -�� N -f� - Water Supply: Public system ❑ Community system ❑ Private �pth t ater Table -------- 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--------------------} No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well---3 ---Distant ftom f�ndation-----� __.----.Mat r ial----�:f/--- -r--------------------- '� No. of compartments-._-�----_- ,erg 4'&� Liquid depth---- ---------------Capacity.. Size. Dispos Field: Distance from nearest well__�4_1_Distance from foundation-----fU-_--_----Distance to nearest lot liner_--.-- ----- e l Number of lines------ ------ --------------Length of each line----$V-..------ ------.Width of french.---Z----- -----------_--.--- <J„- Type of filter material- CX ------ of filter material.- ,-141----------- length---.----- 16-6---------------------- rp Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-----.--_-------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------.-------------Depth----------.-------------- I 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-------------------------------.---- Distanceto nearest lot line------------------------ ------------------------------------------------------------------------------------------------- I 1 Remodeling and/or repairing (describe}- --------------------------------------------------- --------------•--•-----------------------------------------•-------- •------------------• ----------------------------•---------------•-------------------------------------------------------------------------------------------------------------------------------------------------------- ------ { -------- --� ----------------• ----------------•------------------------------------------------------••-----•----•-•--------------------•----------------•--------------- ------ i ------------- ------ ---------------------•----•---•---------•--------------•-------•-------------------------------------------------------------------------------------------------- 'll 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 re ulations of the San Joaquin Local Health District. -------------------------------------------------------------- Fd/or Contractor) (Signed)--------------------- - --------------- -------------- ------- -------- ------ --- ---- ---- ---------- - ..-------------------(T.itle)-------------------------- ------ - ----.-.-..-------- --------- (Plot plan, showing size of loft, location of system in rel ion to we buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----_Cl....... s------- -- ------------------------------------------------------- DATE------10------z 7.:.. -------- ----------------- REVIEWEDBY-------------------------------------- -- -------------------- --- ----------------------------------------- ------------ DATE--------------:--------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE------------------------------------------------•----------- Alterationsand/or recommendations--------------------------------------- -------------- --------------------------•---------•--.------------------------------------•-----••------------------- FINAL INSPECTION BY --------------- Date... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED B-54 3M 3-'63 F.P-CO. r