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VUK Ut-HUI: USE: r 4 w -_s /_ r_.-__- -: __-_ -__.__3- Q-_ APPLICATION FOR SANITATION PERMIT Permit No.-------- -- (Complete in Duplicate) ---------- --- This Permit Expires i Year From Date Issued Date Issued Application is hereby made to fhe San Joaquin Local Health District for a permit to construct and install the woD Q"?in/dgo ib This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND ATION __..-71fJ *E- N/ L_ ..�- f� i� � - Owner's Name 11 ' Address ----------- Contractor's Name--------- t.- 'n------ d Phone--------------- ------------------ Installation will serve: Residence ❑ Apartment House ❑ Com rr ercial Trailer Court k ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths _______ Lot size ___________________I ..CL _--_-_--_--_-___-_ Water Supply: Public system ❑ Community system Privateeph to Water Table Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy'Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (if yes,date------.---- --------) No New Construction: Yes No FHA A: Yes El N6 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------------.-------Material____--_____.___.________________ El No. of compartments------- ------------------Size--------------------------------Liquid depth--------------- ------Capacity----------------------- Disposal Field: Distance from nearest well. .............Distance from foundation..------------------Distance to nearest lot line----------------- ~ ❑ Number of lines----------------_,-----------------Length of each line------------------------------Width of trench------------------ ,- '� 1 ype o filter material___________________..__Depth of filter material----------------------- length------------------------------------------- Seepage --_____-__________________________-__-___ SeepagePttDistance to nearest well.- a '' t-Distance f m foundation_;,-/0_-----_._.Dis ante to nearest lot line_,SJ_�-__ Ct.0 -Size: Diameter-_____ - . Number of pits_..__-_____�---------Lining matercal___ _____-_DepthG ,67_ �2-�. Cesspool: t�" Distance from nearest well________________Distance from foundation-------_---- --------Lining material------------------------------------- F-1 Size: Diameter------------------------- ------------Depth---------------------------------- -----------------Liquid Capacity---------------------------.gals. Privy: Distance from nearest well-___________________________ >-_=:_--______Distance from nearest building ❑ Distance to nearest lot line__________________ - ------------------------------------------------------------- Remodeling and/or repairing (descriibe)---------------- --------------------- --------------------•--------------------------------------------- ---------•----------------------- ------------------------------•---------------•---------------•----------------------------------------------- I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State 1 d rules and re ions of the San Joaquin Local Health District. (Signed) ----- - � -- ---- -----(Owner and/or Contractor) By:---------------------------- ------- -------- )---------- ------(Title)------ r -'x/}`a_, 1.. ------ (Plot plan, showing size of I t, Iota ion of system in relation to wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-.-._`" !-- -------- -- -----F-� ___ -' DATE----- --- -------------------------- IWED BY-------------------------------------- ------------ ----- ----------------- -- DATE------- --------------•-------------------- - -------- BUILDING PERMIT ISSUED----------------------- - ------ DATE - ---------------------------------------------------------------- Alterations and/or recomendatio s:-_________-------- ----- -s'�- - '- -- .---- --------------- ` =-------------- •- ------------- --- --- - -- -- ----- FINAL INSPECTION BY:__ /(�,_/�.--•-- � �' � �� f Date - ------------- Y 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 ES 9 REVISED a-59 3M 3-'63 F.F.CR. - Ill,