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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT Permit No. .- ...... ----- ----------- ---------- --- ----------------------- ------ ----------------------- -------- ----------- (Complete in Duplicate) Date Issued ------------------------------ -------------------------- This Permit Expires 1 Year From Date Issued 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 Cou�Td No. 549. JOB ADDRESS AN LOCATION/ Owner's Name----- -- ---- - ---- -�` Z& ^--------- --- ---------------- �' Phone------------------------ Address--------s ....-r- � a �'_ s #.. - _ ._ �. _ R _ .w Contractor's Name------ ----------------------•---------...----•---....-------------•----- -------•---------- Phone---•----•--••--•--------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: ___!___ Number of bedrooms _' __ Number of baths ___!__ Lot1size ____ p_ `4 _______________________________ Water Supply: Public system ❑ Community system Ll Private [ epth to 1Nater Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay (] Adobe(Y--IFfiardpan ❑ Previous Application Made: (If yes,date_..__.___'___-.___) No P�--New Construction. Yes �o ❑ FHA/VA: Yes ❑ No 2�-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) /f Septic Tank: Distance from nearest well-_:t570___.__Distance from foundation_•._____p---------Material____--___________________________________________ No. of compartments--- -----------------size---- ------Liquid de th__,____-_'-_ - Ca Capacity LP- Disposal -- Field: Distance from nearest welL:_�'o___..._Distance from foundation_d_________-Distance to nearest lot line__�__ ___- ❑ �_ Number of lines_____!_____ Length of each line__ 'i--�'----------------Width of trench._`�-_9 `= Type of filter material ____-_-__Depth of filter material_._�!_�_________,_____Total length____7�_____________________________ -- Seepage Pit: Distance to nearest ---------Distan m fondation_- Z_ ......___.Distar�ce to nearest lot line------ _—_____ Tr___ Number of pits-----!---------------Lining material___ ------- ....Size: Diameter-----q3______-----Dept h_._..! ------------------- r Cesspool: Distance from nearest well__`______________Distance from foundation------------------- Lining material________.._.___.________________-__-_ Size: Diameter--- --------------------$--------------Depth-----------------------------------------------------Liquid Capacity -------gals. vY Privy: Distance from nearest well-----___------------------- --------.------------Distance from nearest building__________-____________________.____-_-_. Distance to nearest lot line_r_______________ t ._._;-------�n------------ t�t 1 � � Remodeling and/or repairing (describe) 3------------------- `t -----•--•-------••--------- ------------------------------------- --- _____________________________________________________________________________..__-_____________________-__3_________________________.____--__.__-.-------------------------------- ----------------------------------------- _____--________________________._______-_____.______________-________._ 3 l + I 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rulesnand regulations of the San Joaquin Local Health District. I -___.___.Owner and/or Contractor (Signed)-------------------------�--------------------- - - - - ( ) By: Title Y•--------_- ---- = ----- ------- --------- (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-------- -r== DATE / REVIEWED BY---------------------------------------------I-------------------------------------------------------------------------------- DATE-------------------•------------------- ------------------- BUILDINGPERMIT ISSUED----------------------------•- --_---------------------------------------------------------------- DATE--------------------------------------------- --------------- Alterations and or recommendations:______-..- ..�_—` � ¢e,==�- _..__-___S= �-- ----------------i-- -- - - - ---------- -------------- =� -- f . .......... r .----•- ------ -- -- ¢ � `mss /j .. l:.• Alfyj�-s�� 2%� FINAL INSPECTION BY:... �`Ll _.----- Date._- �Y l C [CC � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,Californiw' -- Manteca,California Tracy,California CS 9 nrviSED 8-59 3M 3-163 F.P.DD. r