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FOR OFFICE USE; -------- f APPLICATION FOR SANITATION PERMIT Permit No. -•---•--•-- •••- ----- -- -------- -------- - ----------- (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued Application isherebymade to the San Joaquin Local Health District for a permit to construct and install the work here-:n described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------1_ff------a---f-----=--------�� -�----��- -- ------ ---------------------------------------------•-•- -----•-•----------------------- �----• •-- --L-- ------ Owner's Name__._ ------------------- -- --- .. Phone ,,.. ------------ Address------ = - { f '/------ -•------------------------------------------------------------••----- ---------------••--------------- Contractor's Name---- fir --- -•--------------- -•--------•••-----------------•---I-------------------------------------------------------------- Phone------------•-------••------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _v-,Number of baths _1___ Lot size __ --------------- --------. ---------------------/ Water Supply: Public system �ornmunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandym Loa ❑ Clay Loam ❑ Clay ❑ Adobe [3Hardpan Previous Application Made: (If yes,date:.---------,--------) No 5?"'N ew Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: �. Distance from nearest well-----------------Distance from foundation____________________Material____________.____._____._______---....________- ❑ `/��C"'AJNo. of compartments_ '__-----•-----size--------------------------------Liquid depth--------------------------Capacity----------------------- // nistance from foundation,----- _e�_-__.Distance to nearest lot lire Dispos I Field � Distance from nearest well__ ❑ `� " lumbar of lines__.____ _... � line_1_ f-__ Width of trench..... -- . 00 Type of filter material_yipG_____- ____Depth off filteh,materiai____.l �J___,Total .length____.__ ` ____ 3c2`_____.. _ 9 Seepage Pit: Distance to nearest well---------------------Distance from foundation----------.---------Distance to nearest lot line____________-__.- S' ❑ Number of pits.--------------------Lining material-----------------____=-Size:•Diameter---"----------_-.---Dept h----------------.-.-------------- Cesspool: Distance from nearest well----_------------Distance from foundation--------------------Lining material------._._.._-______.____-_-____.._ . [� Size: Diameter--------------------------------------De th--------------------i --------------------------- Liquid Capacity gals. _ Depth r ' Privy: Distance from nearest well---------------------------- ----------------Distance from nearest building________-__-________________-_-._____..._. ❑ Distance to nearest lot line---------_------- ------------ " Ir Remodeling and/or repairing (describe]---------- ------------------------------- --------- --�------ --------------------------------------• `r Y � ----------------------- --------------- ----- -----------=-------- ------------ ----- --- -•--•-----=------ - -----------------:---------------------------------------.-------------------:------- 1 I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin County ordinanceseSfate ws, and ru{es gd regulations of the San Joaquin Lacal Hea{th Distrvct. /f/J{Signed]; =14�' - v'"� >ion ------ {Owner and/or Contractor] By:--------------------------------------------- ---------:--------------- --- -------------- ---------- ------------(Title)----------------------- (Plot plan, showing size of lot, location of system in relyo wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY G ' APPLICATION ACCEPTED BY_ - " __—: DATE { —------------------- REVIEWEDBY----------------------------------------------------------------- ----------------------------------- --------- ------ DATE-------- -------------------------------------------•------- BUILDING PERMIT ISSUED----•-•----------------------------- R_: - -------------- DATE.-------------- - -- - ---------------------- - -� ------- Alterations and/or recommendations' ------ --- - u. --s- � ''` � ----------�----------------------_- -- _ w _ .y c:c :�sJr------------ =--- ---------•-•-------- t --------------------- -------------------•------------------------- j FINAL INSPECTION BY: 7 : :_ ----------------------------- PAN hlJ N± Date.----- L AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 00 West Oak Street 124 Sycamore Street 205 West 9th Street t Stockton,California Lodi,California Manteca,California Tracy,California ES % REVISED 6-54 3M 3-'63 F.P.CO.