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FOROFFICE USE: .76 _ll� --- ------------- 0__4 APPLICATION FOR SANITATION PERMIT Permit No. �� _ -------- ((Complete in Duplicate) Date 'Issued --- ------- -Z#------- TExpires Year From ate Issued ! plication i ereby made to the San Joaquin Local Health District for permit t n q p o construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------4�----- .< Owner's Name-------------- Address -------------�'' Address----------••---_--•---- _67-----.. ta- J ..�T -- 7- --------•-•---•----------------------------------- Contractor's Name----------•----- -- 1 _(S% f----. 1ti/ ----------------------------- -T Q Installation will serve: Residence [& Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. ___l___ Number of bedrooms ---I— Number of baths --- Lot size ----7tJ�__-_X---/--,>_ Water Supply: Public system ;K Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0? Clay ❑ Adobe❑ Hardpan ❑ Previous. Application Made: (If yes,date...............-----) No R, New Construction: Yes ❑ No M FHA/VA: Yes ❑ No,K 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-----------------Distance from foundation--------------------Materiai------------._..-_.___------__-______._.______. ❑ tA No. of compartments--------------------------Size-------------------------------Liquid depth__.-----------------------Capacity------------•---------- Disposal Field: Distance from nearest well-----------------Distance from foundation._._1/4�-----------Distance to nearest lot line------_--_------ efxl.5rl -' Number of lines---------------r ..._--_-__ ._Length of each line-------/_ �� Width of trench _- -- 1 .. Add Type of filter mate ria l___-_'45_5,��_-Depth of filter material----I8__________Total length__-.-_---..-/.�__------------------- i Seepage Pit: Distance to nearest welt____________________>Distance fr9rn foundation_____- ____.Distance to nearest lot line-----..S_LK f� Number of pits--------l------_----Lining mate Size: Diameter._..,- -------Depth___ _____________ Cesspool: Distance from nearest well-----------------Distance from foundation--------- ----------Lining material-___-..____--_--_______-__-_--___---. ❑ Size: Diameter------------------------------------ Depth---------------------------------------------------.Liquid Capacity-- -------------------------gals. Privy: Distance from nearest well_----_______________________________M_.---------Distance from nearest building----------------------------------._____- ❑ Distance to nearest lot line Remodeling and/or repairing (describe):---✓ 1Ic/----Vii'.-_-_ __1�!/ill-- '-___-____ -------------------• ---------------------------------------------------------------------------------------------------------------.--------------------------- -------------------------------------- -----------------------------•------- -----•-- -------_---- ----------------- ------------------------------------•-.-----------------------------------.-------------------------------- 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. ,,rte �+ (Signed)------------- y �'d /1= ,J.-1~3! - ,/ ----------------------------------------------------------------------- Owner nd/or Contractor) SY: 2------ ---- ------------------------------------------------------(Title)------------- --------- - -- --- (Plot plan, showing size of lot, locat n of system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- < -- ----------- ------------- DATE----- --------------------------------------- --------------------------- REVIEWEDBY----------------------------------------•-------------------------------------------------------------•--------------------- DATE---------------------- BUILDINGPERMIT ISSUED-----•------------------------------------------------------- --------------------------------------- DATE------------------------- --------and/or recomm dations-------------------------- - ---------------- ------------- ----------------------------- ---- - - ------------ - - ------ --- - ---- - 11- , y --�- .�� ------- ------------- ---- dL s�_-__ .. . -------------------------------------------------_-.--------- - -------- ----------- FINAL INSPECTION BY:------- < l�`�L6-7 j` i?7�e---- --------------- Date----- --------------------- . . .................................... -------------------- .. --- . --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California r ES 9 REVISED 8-59 3M 3-'63 F.P.CO-