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F R0IIICE;USE• :+ _ 1 � APPLICATION FOR SANITATION PERMIT Permit No. ....J-72.C_j.3 - --------------------------------------------------------- (Complete in Duplicated / Date Issued ..__ ------------------------------------------------------ ___ This Permit Expires 1 Year From Date Issued 1-- __ _ s 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 N 549, JOB ADDRESS TION__ ._ff�_�_ Owner's Name --- -- -- --- - -------------- Phone1 ,�---3 Address------------------------- ----- - --------------- ---....---------_ - ---------- •.... ------------- --------------------------- ------------------- -------- Contractor's Nam - -------------------------- ------ t --- --- C L-� ---- ----1--------- Phone i z fJ ` Y Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Nu ber of bedrooms _7 Number of baths _�____ Lot size 40 67 -7 47- ,��ber ---------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑. Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2-"Aardpan ❑ Previous Application Made: (If yes,date---------..---------) No E] New Construction: Yes ❑ No �FiA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic t or cesspool permitted if public sewer is available within 200 feet.) t is Distance from nearest well_________________Distance from foundation--------------------Material ____________.._____________________-__.-_---. No. of compartments----------- ---Size--------------------------------Liquid depth-------------------------Capacity--------------- ------- �pis osa field Distance from In well_tAD-LI,@___Distance from foundation.. .� y ,LQ___------Distance to nearest lot line---- r' � Number of lines_________ _ ____________ Length of each line_- -P--------Width of trench._,�_ �!------------------ --------- __________-..___ 6 Type of filter material '¢ ___Depth of filter material____.____/_r/__Y___Total length-----------------�----------------- -—-------- y f.Seepage Pit: Distance to nearest well_ p-g-a-------Distance from foundation____ _,_.Distance to nearest lot line------ i Number of pits---l --------- g �i f Depth_ _, Cn l Linin material_ pclK__..._-.size: Diameter:___ 1 , Cesspool: Distance from nearest well_________________Distance from foundation material_-_._-._________._..__..________ E] Size: Diameter--------------------------------------Depth----------------=-----------------------------------Liquid Capacity---------------------- -----gals. Priv Distance from nearest well_________________ ________Distance from nearest building9 ❑ Distance to nearest lot line---------------.----__--_------------------.----------------------- Remodeling and/or repairing (describe____________________ ' t� - --------•----------- --. ------•---------- -------------------------------------•----•------•------------•-------•--------------------------------••------ ---------- --` -------- ---------------------- -- --- - -- --- -- ------ ------------------------------------------------•------------------------------- { I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ --- . --- {�r Contractor) 1 - � f By:------------------------------- ---------(Title)------ --- ----- ----------- ------------------------------ (Plot ------- --------------------(Plot plan, showing size of lot, location of system in relation t ells, building et ., can be placed on:reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY----------- •--' --------------------------------------------------------------- DATE------ 77. ./5-_/-------- ----------------- ] REVIEWEDBY---------------------------- -------------------- ---------------------------`------------------------------------------------ DATE----------------------=------------------------------------ $UILDING PERMIT ISSUED____ -------------------------------------------- DATE------------------------------------------------------------ Alterns and/or recommend tions----------------------- --------------------- �.. --- -...------a-'T--f--------- ' "`-"" - ---a� r------------'°_c- __-7e ------ ---------------------- ------- ------------------------------------------------------------------------------------------------------ ------------•----------------------------------------------------------------------- ---------------------------------------- ----------------------------- --------- ---------------------------------------------------------------------------- ------------------------------------------------------------- _-_ .t3'�__________________ _.. �--------- -------------------.. . 8 n� FINAL INSPECTION BY: a Date - ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazollon Avo. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Codi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD.