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rUK Uf-HU USE; ---------- ----------- APPLICATION FOR SANITATION PERMIT Permit No. _/.1212-_... ----------------- ---------------------- --------------- r (Complete in Duplicate) ------------ ------------------------------------ This Permit Expires 1 Year From Date Issued 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-applicat ion,is,.made,in"compliance with County Ordinance No..549. JOB ADDRESS'ACAT ON-IM-m4--- � Owners Name __ . `fl Phone y� Address-__._ ------•---•--- -------------------=----- ----••----------•- Contractor's Name _ ------------ Phone.... ------•-----------_-- Installation will serve: Residence Apa-rtmen House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-- Number of bedroomsX___- Number f baths _Z_ Lot size ------- Water Supply: Public system ❑ Community system 0 zvate Depth t" 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- } No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if-public sewer is available within 200 feet.) Septic Distance from nearest well....... Dista rre from fFundation--.--- `__.Material_---.-_ _. No, of compartments . ' --Size- :-_. ,/ /t ' p �4 xh--. quid deRth = Capacity-----/._0.6 Disposa field: Distance from nearest well---q..SE -.:__Distance from foundation_----- _. _ _ ------.Distance to nearest lot line-5- of lines--_-___-_Is _ Length of ea h line--.--��:_�-"�' `---.Width of trench--. --- r Type of filter material_•_ / +�---..---Depth of filter material-- length ------------------_-- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---------- ---- ) ❑ Number of pits------ --------------Lining material-___---.-.---_-_------Size: Diameter------------------------Depth------------------------ _.. ....................... Cesspool: Cesspool: Distance from nearest well-----------------Distance from foundation------------- ------Lining material--_---------------_--_.---_.-.- El Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---- „----------______---------- --- ------..._Distance from nearest.building.--.--.--____--_-_---._- - - El Distance to nearest lot line----- " r (describe ' � = ;. <. �---- ---- `' -------------- ------- --.-;—?rr. . - --- ----------- M -- - a7:��_ _i----- _� --------------------------------------------------------- ------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stafe s, and rules and regulations of the San Joaquin Local Health District. (Signed)----------- ------- --- -------- --- --- -------- Contractor)r ' itle)_ - ------------ - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -- - _ - -- - - -_--- -•-- DATE-- G S""________ REVIEWEDBY------------------------------------------------------- -------------------•---------------------------------------- DATE---- •----- BUILDING PERMIT PERMIT ISSUED---.-•----------------------------------------------------------------------------------------------- DATE ------------------------------ Alterations and/or recommendations:-------------------------- --------------------------------------------- ----------- ---------- ----•------------ --------------•------•--- -------•---------------- ----------------------------- -------------------- ----------------------------------------------------:-•--------------••---------------------•----•---•-----•------------------------------------ ------------- -----------------------------•---------•-•---- ----------------------------------------•--------- ..---------------- -------------- FINAL INSPECTION BY:- -. _ ' m ? � Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED H-59 3M 3-'63 F.P.CC. -