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FOR OFFICE USE: ----------- ------------------------------------- ---------------------------------------------------- --- APPLICATION FOR SANITATION PERMIT Permit No. _l fT�/ Y ------------------------------------------------------ (Complete in Duplicate) i Date Issued --------------------------------------------------------- This Permit Expires 1 Year From Date Issued i' , 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. Z Lt?A_ VV �, y _ � � � { JOB ADDRESS AND LOCATION - 1.1-' _'?- ------ �� // 87 `� A�-._ Owner's Name - Phone-------------------------------•---- ---------------- Address------------------ 4 ------0��- ��-'------. Contractor's Name------_------_------•---------------•--•---•-----•-------------------------------------------•- --------------------------------•--•--- Phone------..----------------•---_---- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A___ Number of bedrooms ____ Number of baths 1____ Lot size -1-Me _____________________________ Water Supply: Public system ❑ Community system ❑ Private I� Depth to Water Table 19 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam W Clay Loam [❑ Clay [❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No [jo 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.) N Septic Tank: Distance from nearest well_zr`_4_ •-a'_-___Distancg fr foundation__�d-_____-__.Material_____________ ___________________________________ ��- (V Dd No. of compartments---- -----------------Size 'rf i'-�-------Liquid depth-------y----------------Capacityl 01-------- 4 Disposal Field: Distance from nearest well__A`------Distance from foundation__ &---________-Distance to nearest lot line--- Number of lines_____ _______ _ Length of each line-10 ® � - p------- 9 ---------------------Width of trench_.-.�.-��-------------------- ' Type of filter materia -Depth of filter material-_-_f Total length---a_LgA-_________________________ rlU�� p _ � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--------__-___-__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material____-___--_.____-_--____-_____ 7 ❑ Size: Diameter------- ------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well.--------. --------------------------Distance from nearest building---------- ---------.-------------.-----_- ❑ Distance to nearest lot line-----------------------------I-----------------•-••----•----.....--.-----•-------------------------------------------•----------------------- Remodeling and/or repairing (describe) -----------------------------•--- -----------•--------------- ---------------------------- ---•------------------------------------------ ----------------------------------------------------------------------•-----------------------------------•---•------------------------------------------------------------------- ------------------------ ------------------ ------------------------------------- ---------------- ------------------------------------------1------------------------------------------------------------------------------------------------------------------------ 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, andrul s and regulations of the San Joaquin Local Health District. �� 1 (Signed)----- ----------------------------- ---------------------- --------- ---------- ------ -------(Owner and/or Contractor) By:---------------------------------------------------- --- e ------------------------------------------------------------------- {Ti+l )------- -- --------------------------------- -- ......... - (Plot plan, showing size of lot, locat' of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------ ---- DATE------ -------------------------- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMITISSUED--------------------------------- ------------------ - ---- ----------------------------- ATE------- --- era+ioos and or recomme dations:__-___-___ v___-___ y ----- ---- - -- - ------ . '" ' -------- -- -------------- ----------------------- ------l------ ------ •--- -- - ------------- ------•------ - -----�---------- -------------------------------------------- f _ ---s = - -------------------------------------------- -------------------------- -------- ---- ---------- ------ --------------------------- - - ---_:- = �� ----------------------- J , FINAL INSPECTION BY------------------------------------------ -------3-;, 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 ES 9 REV15ED B-59 3M 3-'63 F.P.CC. -: r