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FOR OFFICE USE: �} -y - (/I r rIF / ---- -------- ___ ______________ __ APPLICATION FOR SANITATION PERMIT Permit No. . IfP _ _ --------- --------- -------- - (Complete in Duplicate) Date Issued ____ _t 71 --------------------------- 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. 2l VV JOB ADDRIESS AND Owner's Name-----' emextl ------- -------------"-"------- ------------ Phone----------------------------------- Address------------------------------ ............. J ------------- ----•------- _17 1114 . Contrac#or's Name---- Qit� f/ fi+� _._...-- --f •'. ----------------------------- J _ '-- ioiie-------------------------- Installation will serve: Residence T Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___;r___ Number of bedrooms --- Number of baths _ _ Lot sizeF________ ------------------- Water Supply: Public system ❑ Community system ❑ Private 10 Depth to Water Table _e-p ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 21 Clay Loam [❑ Clay ❑ Adobe ❑ Hardpan Q Previous Application Made: (If yes,date--------------------) No (p New Construction: Yes k No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well_____-__Distan frog�J foundation____/_0_______.Material____ ___--___-_______- 20 No. of compartments-____P_-_-________- -.-Size-=I_!'�-bIr- ---Liquid depth----------r-----------Capacity_``s --------- Disposal Field: Distance from neares wells0-------_Distance from foundation._A!?�----------Distance to nearest lot line___________ ] _._."_________Length of each line____ 0___ Width of trench-_----_�"___________________ Number of lines_____ _______ ___ _ Type of filter materiel Depth of filter material---) -'--------"Total length----3 ;K----------------------- 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-------------------------------------: ❑ Size: Diameter----------------- -------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------_------------------------------------------Distance from nearest building____--____________-__-_______---__-____-- ❑ Distance to nearest lot line-------- ------------ ---------- - -------- ---------------------------------------------------------------------------------------------- L Remodelingand/or repairing (describe):------ ------------- ---------------- ------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------•---------------------•---- --•----•-•--------------•--------------------------------------------------------------------------------------- ----- -- -----------------------------------------------------------------------------------------------------•------------------------------------------------------------------------"----"----------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lar,,.6 and rules and r9gulations of the San Joaquin Local Health District. (Sign ___________________________(Owner and/or Contractor) BY -_`-------- ------- --- - - ---= --- - - (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY N APPLICATION ACCEPTED ------------------------------"----------------------- DATE------;7—WG -3----------- - ------------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------•---------------------------------------------------•--------"-------•------------------------------ --------------------------------------------------------------------------------------------------- ----------------------------------------- ----------•--•---•-------•---•----------------------------------•----------- ---------- -------------------------------------------•------------------------------------------------•-------------------------------------------------------------------------------- ----------------•------------------- -------------------------------------------------------•---------_-----•------------------------------------------------------------------------------------------------------------------- - -------------------------------- ----------------------------------------------------------------------------- -------- --------------------- -------------------------------------------•----------------------- ------------ ------------------------------- FINAL INSPECTION BY: RsDate - ZO------ ------------ "6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hamllon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD. 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