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FOR OFFICE USE: ------------------------------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. ..�_ �- ------------------ --- - - (Complete in Duplicate) - /j� Date issued ___ _!'�C_S_ ----- 1_ � - ------- -------------- 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 Ordinance No. 549. i JOB ADDRESS AND LOCATIO -- _ _ - --- ` .._4_"-�' `�----- ------------ •[t}ta.�� 1 . --------------------------------- -- -- Owner's Name-------- -- -------- - Q D.� - n t7 _e) I d# - ' Phone__...... -- ------- - ---- -----------•---••-----•---- 1 - Address-----•--- - ----- --- ---- -- -----L.�r!-t ------------------------ --------------------------------_--------------`%....-----•-•---------. ------------ ------- . Contractor's EName ...-; - r 'Phone.... ................. . Installation will serve: Residence Apartment House ❑ Commercial ❑ Traile/Court`D Motel^ ❑ Other ❑ ' Number of living units: __I___ Number of bedrooms _3___ Number of baths �-_,Lot size _"_"--____I--------------"__--- Water Supply: Public system ❑ Community system ❑ Private C�_,Depth-to.W'ater Table__"_'___eft.. I Character of,soil to a depth of 3 feet: Sand 0 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.) r t Septic an1;:' Distance from nearest well------- Distance from f undation---J0--_.---.--.Material__------ ------ - --- ----------- ------- i No. of compartments _____ ______—- - - dd$ p Size---�--`---�-f---��__Liquid depth------ -------------Capacity--- - Dispos Field: Distance from nearestell-----4"P!...Distance from foundafio�._.��__�.__....Pistance to nearest lot lines �.--i-_. [ r Number of lines"_-._____. -------------------Length of each line._ 0_ -_/ b_.-1Width of trench.. --- y__.___ J, Type of filter rnaferia1_____-d1_x_t___-"Depth of filter material------ ...........Total length""""_•4.q-"0----------------------, I Seepage,Pit: Distance to nearest well------ ------_--------Distance from foundation-------------------.Distance to nearest lot line__.._....._._-_..� � ❑ `r I Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---- _------------------------- Cr Cesspoo'I: i Distance from nearest well-----------------Distance from foundation--------------------Lining material__-____"______-_---"-._______--� ❑ t Size: Diameter----------------------- ---------- ---Depth--------------------------------------------------.-Liquid Capacity- ------------------------gals., Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------.-. ----------.----- ❑ " Distance to nearest lot line__________________________________________ -------------- Remodeling and/or repairing (describe) ---------------------------------------------------=---------------•------------------------------------------------------- -------------Z +--'----------------------------- _ _-------_--_-------_ _._.__—_ —_ ==—= -----------------�- :---------------_ ---------_—' --=-------------------------- ------------------- 1------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- - --------------------------------------------------------------------------------------------------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 and regulations of the San Joaquin Local Health District. (Signed) g g-- { ---------• - __Pw"e and/or Contractor) Si ned __Title (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.. . . ------------------------------------------------ DATE----- l!.-'� ..................... --------- REVIEWEDrBY------------------------------------------------------------------------------ --------------------------------------------- DATE-------- ---•---------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------ Alterationsand/or recommendations:----------------------------------------------------------------------------------------------•-••-----•---------------------------------------•-------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------•-------------------------------•-------------------------------------- -----------------------------=------------------------------------------------------------------------------------------------- ------------------- ------------------------ ------------------------------------------------------------------•-------------------------•------.. -------------"---•------•-------------- ------------------------------- 1 FINAL INSPECTION BY:_ 1 Date_.. - ---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street X124 Sycamore Street = 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REvisEO 9-s9 3M 3-'63 F.P.CC. r rl