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FVOIFFICE USE:------- ---------- r Permit No. . APPLICATION FOR SANITATION PERMIT ------------ ------------------------- / ------------------ ------------------ ------------.------- (Complete in Duplicate) Date Issued -------------------------_-------------_ --------- This Permit Expires 1 Year From Date Issued r . 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.. JOBADDRESSA D LOCATION--- _ �✓V,t]-_ ---------------------------••---------------------•------------------ --_---------------------- a -----------------------------------•------------------ ------ Phone----------------------------------- Owner's Name-- -----`----- -- --- --------•--•----•----------•------------•----------•- Address---------4 '+(`-- ------ -=---•---- S --T -----------•--•---------------------•---•--•---------------------•----------------------••- ---------------- Contractor's Name----- Phone. Installation will serve: 'Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--. Number of bedrooms _2.... Number of baths J--- Lot size _._71�1� ------------------ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _60- 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 ta-�FHA/VA: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep Ilan Distance from nearest well-----------------Distance from foundation--------------------Material.-.-.....--.----......-----------------.-.------- No. of compartments--------------------------Size......--------------------------Liquid depth---- ---------------------Capacity---------------%------ Dis a Distance from nearest well_- .............Distance from foundation---/A-t---------Distance to nearest lot line.. Ad( 4 Number of lines-4----------------............._.__Length of each line-_Z.a-_....._ . --------Width of trench.X-9------------------------- J Type of filter material_..l.L QU�__-----Depth of filter material.._/.Y_`_----------Total length------10_---------------------------- Seepage .f-------------------------Seepage Pit: Distance to nearest well---__- --------------Distance from foundation_&-------------Di`stance to nearest lot hne_`�.........-.-. Number of pits------1---------------Lining materiaC__jTjt Q( /(------Size: Diameter---3.....3-----._ Depth-- --0------------------------- Cesspool: - -- -------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------- ....Lining material- -...-- -.-..--_---_._......_._.-.- u�d a ----_ --gals. Size: Diameter--------------------- ----------------Dept h_--------------------------- ------------------ L actiY _ --- Privy- --------------- . 1I1 Distance from nearest well-----------------_.----...----- --.............Distance from nearest building.----.--.-.---------..---.-.----------_-- ❑ Distance to nearest lot line----------------- ---------------- ------------------------------------•-------------- ------------------------------------------------------- 1 Remodelingand/or repairing (describe):-------------- --------------------------------------••-•------------------ •------------------- ------------------------------------------------------- . -------•------•----------•-------------------------------------------------------------------------------•--•----------------------------------------------- ------------------••----------------- ------------- t --------------------------------------- --------------------------------------------------------------------------------•------------------------------------------------------------------- ------------- - 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 ales and regulations of the San Joaquin Local Health District. Si ned r ---------------(Owner and/or Contractor) 9 -- ---- gY�------------ (Title)-- -------------------------- --------- - - ----- --------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_--- = c-c`'' DATE -- 2-- ------------------------ REVIEWEDBY--------------------------------------------- -------- --------------------------- ----------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------•--------------------------------------------- DATE------------------ ----------------------------------------- Alterationsrecomm da ionp: - ------------------ ------------------------------------------------------------------------------------------------------------------------- �� ------------------------------ ----• ---------------- ---------------------- --------------------------- ----------------------------------------------------------------------------------- -------------------------------- FINAL INSPECTION BY ..4:.....L� ---------------------- ----- Date. .------ z (' y------------------------------ 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 rc5 9 REVISED B-59 3M 3-'53 F.P.CO.