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........... APPLICATION FOR SANITATION PERMIT Permit No. ..................... - ................... (Complete in Duplicate) �// C/ This Permit Expires 1 Year From Date Issued Date Issued ..._;I/ �.�/- .�0._1 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. s y Z y £ . C_.E/-c o") f JOB ADDRESS AND LOCATION. = ,.1 ----------'a-�...-----2---------<ID�Z OwnersName.... .. .. .. ............. ..............------. --- . .... ...... Phone.............................. Address `[ _............ .. ----•-..............-----....-_......------------•... •---........ Contractor's Name-a5/ . ,-4 - .-.... I . Phone................................... Installation will serve: Residence IN Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. --/... Number of bedrooms -. � . Number of baths .��, Lot size -...�1 G' E................................... Water Supply: Public system ❑ Community system ❑ Private (�] Depth to Water Table 3.5--ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam X) Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Z) Previous Application Made: (if yes,date--------------------) No to New Construction: Yes No ❑ FHA/VA: Yes ® No ❑ 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...1CI.........Matto ia1--.06�� No, of compartments.......' ..............Size.._ .X.�l'3. 5"..�--Liquid depth.._{/.2._. ...4... Capacity...4. .. Disposal Field: Distance from nearest we!i Distance from foundation_....6.Q..........Distance to nearest lot line...✓....... �] Number of lines........2............. .... Length of each of trench... �.�.............._........ Type of filter materialof filter material----./'?..._._.__Total length---146.7_--___.___.._....- Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line............. ❑ Number of pits... Lining material........... Size: Diameter.-....... Depth ...... f Cesspool: Distance from nearest well.............. ..Distance from foundation..-._+-------------.Lining material........ . .............. (r) Size: Diameter......................................Depth—- ----------------- ............ .. ..Liquid Capacity............................gals. Privy: Distance from nearest well..... ...........................................Distance from nearest building..... ... ..... -. ❑ Distance fo nearest !of line . . .......... ......... ...........................---......- ._. ............- 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, a ws, and les and regulations offhe S Joaquin Local Health District. (Signed) - .. ----------•--- .................... • • ............... . (Owner and/or Contractor) .... �� . _...:.. .............. -- 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 ?. ..Q` .. . ....... . ...... _ . .- DATE.... . . -. REVIEWED BY................ . ..... .... . . . .........._. _. DATE..... ... .. BUILDING PERMIT ISSUED..................................................... ........._...................................... DATE.. ..... . ..... ............ Alterationsand/or recommendations:............................................... .................................. .................................................... ....................... .. .. ...... . _... . ..................-.-........... ............................. ....... ..................................................--.................................---•-•---.... ................... .......... ............................. - ................................................--•---------- ---------------............... ... .... .... .......... .. --- • ... ..........................-........ ................. ........................ ...... ..... .... ................ ... ..........................................................------ ------------------------•-•------------ ............................ FINAL INSPECTB Date...........`x�--Q..7[Y. _.._...... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:elton Ave. 300 West Oak Slreot 124 Sycamore Street 205 West 91h Street Stockton, California Lodi, California Manteca,California Trocy,California ES 9 REVISED 2.69 3M 3-'63 r.P.CD.