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FOR OFFICE USE: --------------------------------------------------------- ------------ _-------------------------- ----- APPLICATION FOR .SANITATION PERMIT Permit No. ��l_�_�.... (Complete in Duplicate) 1— - Date Issued .7 �_____:�-F __________________________-------------------______ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein described. This application is made in compliance ith County Ordinance No. 49 JOB ADDRESS AANLOCATION_/V_ ___-;��_ ---- -- - -- -Owner's Name .. ----•-• ---- ... Phonet, • DAddress------------- ------ --- ------------------------------------ 02-7—D-50 -------------------- ----- - -��--�-`�' Contractors Name----- -------- ----.--.... - ------ -- ---- -- Phone = installation will serve: Residence [qll,,Apartment�House ❑ Commercial ❑ Trailer Court L] Motel [-] Other E]Number of living units: _/__ Number of bedrooms._ Number o.baths ---____ Lot size f Water Supply: Public system El Community system [I Private Depth to Water 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-----------,--------I No ❑ New Construction- Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ s 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----------------- from foundation--------------------Material--------------------------.---------_----------- . f ❑ No. of compartments- ----- - ---------- -----Size--•-----------------------------Liquid depth----------------------Capacity---------------------- Dispo Field: Distance from nearest well-__._6_0----Distance from foundation_________L'___-Distance to nearest lot line____'.J�.__ --- Number of lines--------f.�________------------Length of each line________ 1�_� Width of trench.----.-. ._�..-.---_------------- Type of filter rnaterial._.'5'(,r____.___Depth of filter material_--_-_-_- _tel.-------Total length_____-4__1----------------------_(1 �ge/f'ri- / Distance to nearest well......._ �_�-_Distance from�foundation____ _____.Dtance to nearest lot line__ _-�--. Number of pits-------- ------------Lining material`__. -----Size:L+awe#.,,2__X_../,0_'rDepth...... _"______- Cesspooi: Distance from nearest well----------I------Distance,from foundation------------------- Lining material-------------------------!__-__-._.. [] Size: Diameter------------------------------------.Depth---- ---------------------------------Liquid Capacity------------ ---------------gals. Privy: Distance from nearest well----------------------------------------- _-----Distance-from nearest building____.-____.-_____--________________.._. Q ❑ Distance to nearest lot line--- - ------------------------------------------------------------------------------ ---------------------------------•------------------ O Remodeling and/or repairing (describe)_____________________________________ '1 ---------------------------•-----------------------------------------------•----------------------------------------------------------------•----- -------------------------------------------------------------------------- -----------------------------•------------------------------------------------------=------------------------------------------_----•-------------•----------•--------------- - I hereby certify that I ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, d ules and regulations o_f the San Joaquin Local Health District. ----- i (Signed)------------------------ ---- -- ------------------ ----- -------- _ - fir and/or Contractor) _ `_ g {Tit e)Y—.� ----- �---� ��- -- (Plot plan, showing size of lot, location of system in relation to w s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY-- --------------------------------------------------------- DATE-- ,,,�-_'�� -6`--------------------------------- REVIEWEDBY--------- -------------------- -------- ----------------------- -----------------------------------------------------------DATE--- ----= ING aPERMIT ISSUED 1;= k _ 1 '- --_ DATE:------=---------------- Altert ons and/or - ------ -------- ------------------------------ ----• ------------------------ ----------------••-------------------------------•----------------- ----- ------------------------•---------- --------------- -------------------------------•--------------------------------------- --------------------- ------------------------------------------------------ - -----------------------•-------------------------------- -----------------------------•-----------------------------.----••---•--------------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------I--------------------- ----------------- FINAL INSPECTION BY:. ---------------- - Date. ' _ ------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 west Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California �,- ES 9 REVMrO B-59 3M 3-'63 F.P.CC.