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F9R OFFICE USE: -----0 -- ..�S r _____________________________--------_------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) /�_ Z G3 --------------- This Permit Expires 1 Year From Date Issued Date Issued __/_0- 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. JOBADDRESS AND LOCATI N------t V_.J ., i ------------------------------------------------------------------------------------------------------ Owner's Name----------- A ------------------- Phone-----•-----_----------- Address- -. ., I_ ^-- ---- ---------- Contractor's Name -- Phone--------------- Installation will serve: Residence ��partment House ❑ Commercial F] Trailer Court ❑ o el ❑ Othe ❑ Number of living units: ___I___- Number of bedrooms -3--- Number of baths __j---- Lot size _-.- -l!-__- /rS .____________________ Water Supply: Public system E] Community system El Private ❑ Depth to Water Table _______Qt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ S ndy Loam ❑ Clay`Loam ❑ Clay Adobe �lardpan ❑ Previous Application Made: If es,date.._..___..__ pp ( y _ ___--_) No � New Construction: Yes ❑ No FHA/VA: Yes ❑ No �f TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septicqie7ld:k� istance from nearest well___.____-___.-__Distance from foundation--------_-----------Materia{________________________..______._----.________- o. of?compartments--------------------- ----Size...-----------------------------Liquid depth-------- y --------------- Capacit ---------------------- Disposistance from nearest well_________________Distance from foundation---------_ ---------Distance to nearest lot line___________.--__. ❑ Number of lines-------_------------------_-------Length of each line--------------------- -----.Width of trench.___-_____________...__.-___-.,._ Type of filter material--------------------------Depth of filter material_______-______-__._Total length------------- -----------�- 1 4 Seepag it: Dis#an ke to nearest well.�" �__._______Distanfr�om f undation__ �___.________.Dista Distance to nearest to line___J_.____-___.- Number of pits-,/-_______________Lining material__ -�}�__...Size: Diameter.�73--....______-Depth___��.__________-..- t 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------------------------------------------ F1 Distance to nearest lot line-------------------------- Remodelingand/or repairing (describe):--------- --------------------------- -------------------------------------------------•----------------------------•---•-------------------------------- -------------------•-----••-----------------------------------•------------------------------••--------••----•------------------------------------ ------------------------------------------------------------------------- ----------------------------------------------------------•---------------------- ----•-- ----=------------ ---••---------------------------•-----------•-------------------------------------------------------------------- I hereby certify that I have prepared thi app' ation a that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regula ons f the Sa Joaquin Local Health District. (Signed)------------------------------------ -- ---------------- - - - -------------- -------- ------:----------------------------------------•-------------------(Owner and/or Contractor) By:-------.......•••--•----------- --------- -- ---- ----- ------------------------------------------(Title)------- ------------------ --- --- ---- --------- (Plot plan, showing size of lot, n of s tam in ref tion to wells, building's, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- --_/ _ ---------------- DATE---- V 677 /E , / --------------------------- REVIEWEDBY--------------------------------------------- ------------------- ------------ ----- ---------------• DATE----------- BUILDING PERMIT ISSUED-------------------------------------------- ----------------•---------------------------------------• DATE--------- ------------------------------------------•-------- Alterationsand/or recommendations:-----------------------------------------------•-----------------------.--------------------------------------------------------------------------------------- --------------------------------------------------------- •----------------- ----------------------- --- ----------------------------------------------------•--•-------------------------------------------•-•-------------- -------------------------------------------------------•------- -------------------- ------------------------------------------------ ------------------------------------------------------------------------------------ --------------------------------------------- --- ----------------------------------- ----------------------- •----------------------------------•------------------------------------------- -----------------------•.--- ' Date --�/ l s-7 FINAL INSPECTION BY:. «per..------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-SS 3M 3-'63 F.P.CD.