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FOR OFFICE USE: -IN --------------------------------------------------------- -----------_---------------- -------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------ ------------------------------ ------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued r q' l 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,rwith Count 0 clinanc No. 549. zQo r T � * JOB ADDRESS A D LOC TION. A-1, - ` Owner's Name--- ---- -- •- ------- ---------------------------------- Phone Address11 ------.. . - --•• i1. ; . Contractor's Name------------- . ....-- - -------------•------------- ------------••----------------------------•----------------•-------------------- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court [I Motel El/Other ❑ Number of living units: _ _-___ Number of bedrooms __:_J Number of baths _- Lot size ----- _ ----- Water Supply: Public system E] Community system ElPrivate� Depth to Water Table ___ _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Y, Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date___________________) No [ New Construction: Yes No ❑ FHA/VA: Yes ❑ No .-TYPE'OI±-INSTALLATION.-AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available'within 200 feet.) r Septic Tank: Distance from nearest well___ _ __Distan if Mound tion____!!__t7__-..-..Mater i ____ - __________________ --- t --�---------- No. of compartments___--:_______ size-' x___ ____ Liquid deiath�_A Capacity_/��_0_0-_-_-_ x Disposal Field: Distance from nearest weli.__7Q----._Distance from foundation__.�P___..Distance to nearest lot line-___r�—"" Number of lines___.'' Len th of each line_____ _ �------------ 9 �------. IC 7(.).Width of french----- ��-'-�--------------- W Type of filter material__.(_- CDepth of filter material__/9--------------Total length__-_ _______. Seepage Pit: Distance to nearest well_________________ ____Distan`ce'from foundation--------------------Distance to nearest lot Int`------ --------- ❑ Number of pits----------------------Lining material------------------_--:--Size: Diameter---- ------Depth-------------------------------_- Cesspool: Distance from nearest well_____________ Distance from foundation----------.-------- Lining material---------------------------------__. ❑ Size: Diameter--------------------------------------Depth----•--------------•--------------------------------Liquid Capacity----------------------------gals. 1 Privy: _' Distarnce`fr`om nearest well... r�-_._ _"=:`__� -:Distance from nearest building-- ' -- ---------------------------------- ❑ Distance to nearest lot line. - J -------------- Remodelin and/or re air'n (describe): 'f .�� p - r`'f � LQ ---------------------------------------------------------------------- ------- ----------------------------------- --------- - ------ --• --- ------------- --------------------- --------- ------------ ------------------------------------------------------------------------------------------ I hereby certify that I have prepare this application and that the work will be done in accordance with San Joaquin County 't ordinances, State laws, anted rul and r ulations of the San Joaquin Local Health District. \ (Signed)- a ------------------------------------------------ ---------------------------(Owner and/or Contractor) By: ---•-•-- ---------------- �° ' - (rtli)---'-_ --------------------------- (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----------------------------------------------------------------------- ATE------- ------------ �---- REVIEWED BY----------------------------------------------------------------------- DATE------ � i �P BUILDING PERMIT ISSUED - ------- ---- ----------- ----- DATE A .- Alterations and/ar recamrnendations:. =-----------•---------'-----------------------------------------------------------------••------------------------------ --------------------•-----------------------------------------------------------------------------------------------------------------------------•------------------------------ ------------------------------------ ----------I------------------- ---------------------------•----------------------•--- ----------------- -------------------�'�----------------------------------------------------------------------------------------------- I -----•----•------------------------ ---------•-------------- ----------------- - - ----- --------- -- . - ----------•--------/------------------------_ . FINAL INSPECTION BY: ----------------`"--- ------------- Date --lr-� —6--- 6 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,Caiifornicaa ,,: Manteca,California Tracy,California j ES 9 REVISED 8-59 3M 3••63 F.P.M ,