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FOR OFFICE USE: ------------------- ------------ --------------------------------- ---------- -----------------_________________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. _..�_ . ----------------------------- -------: --------- - µ-- + (Complete in Duplicate) 1° 4- This Permit Expires 1 Year From Date Issued 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 mad,e in compliance with County Ordinance No. 549. 4� JOB ADDRESS AND LOCATION__' D___ -_--______ r- � t G � %yc1 ---�. Owner's Name -�1_cg- l -_,- i`YL!4---------•- ---- -------------------------- Phone---------------•-- ---..-•-------- Address---.....-- ..��_ .G_.- � -------- Contractor's Name-•)��l•- 1 -_ - --- Phone _.. --�_ ---•- .3 -�- r� Installation will serve: Residence Apartment House Ef Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living'.,units: '_- '-"Number of bedrooms _t __. Number of baths___I__ Lot size ---_- l '_x____ -_- 1~ � ---- -------------------------- Water Supply: Public-system Community system El Private [I Depth to Water Table ------- ft. Character of soil to a depth of 3 feet:I_Sand'E] Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date._,.._ ._..-------- No ❑ New Construction; Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) _ Septic Tank: distance from nearest well_} .ax;,f.__Distance from foundation____A7_________Material____ _______ ' No, of compartments__I_____. t - Size s -------------Liquid depth------- ;/ -Capacity------------��--d--- F Disposal Field' Q ,Distance from nearest well-c+:��.-;Distance from foundation___l -----------Distanceto nearest lot [� Number of lines__---`-____� ` ----- --------Length of each line_.____.�f__0,1 -__-___ _.Width of french__._ �1��-------__- p �� .,-Type.of,filter mate_riaL___ _________ _______De th of filter material___._��L_________.Tota! length---------_�/___�____._________,_- foundation.-- �"�-�k-ct . �o_ ._.Distance to nearest lot line___._y� -___ � Seepage .Pit: Num Dist 'of to nearest well -----_Distance:fro f pits----- l-__-- Lining material----- QC Size: Diameter_ ,-----------_-----Depth-----121X X-l--?------ � Cesspool: Distance from nearest well-----------------Distance from foundation_...---------____...Lining material---__.__________...___...--________,. ❑ Size: Diameter. --`-------------------------------Dept'h -------------°---------------------------------Liquid Capacity -gals. � .I : Privy: Distance .from nearest well-------------------------------------------------Distance from nearest building- ---------------------------------------- F1 --------------------------------------. ❑ Distance to nearest lot fine----------------- -- 1'S Remodeling and/or repair' g (describe):___-_- A._.___- _- --- _---__ - -_ 1 , - 't ------------ ---------------------------------- -------------------------------- -------------------------- ------------------------------------------------------------------------•----------------------------------------------------------------------------- - I hereby certify that I have prepared this,application and that the work will be done in_accordance with San Joaquin County ordinances, State.. laws, and rules and regulations of the San Joaquin Local Health .District. l -- `c�L` r - --------------------- -------------- ---------- ---------- ---------------- -----(Owner and/or Contractor{ By=-----------•--------------•-------------------.:.--------------------------------------- ----------------------------------------(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 t APPLICATION ACCEPTED BY - - -< —----------------------------------------------- DATE---- - _'_ S` REVIEWEDBY ---------------------------- -- ---------------`------------ -------------------------- ---- DATE---- ---_ --------------------------- ----- BUILDING PERMIT ISSUED------------- - - --- ----------------------- Alterations and/or recommendations: I- ------------------------- - - --------- ' -------•--------------------- ----------------- ------ = ---------------------•---•-- ---------------------------------------------------------------------- -----•----------•---------- F ----------------------- ----------------------------- --------------------------------------------•---------•-----------------•--- ------------------------- --•----------------------------•• --------------------------- . . FINAL INSPECTION BY:.._C..s-� ---------------- ----- --��--- - -- ----•----- Date------- -- ---~- --------------- SAN ------ -'--SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9,REVISED 8799 3M 3-'63 F.P.CO. ,