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FOR OFFICE USE: w ------------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._-•---• --••------ -- -------------------------------------------------------- (Complete in Duplicate) Date Issued ____6 _ __ _0 _______________________________________.____.__--___.___ 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 i st hew k herein described. This application is made in compliance with County Ordinance No. 549, / ryJ.c1(�/L G tri JOB ADDRESS LOCATION_I/`-r¢Y----4- te /La Q ��- -------------------------------------------------------- C Owner's Name- r 'rsJ Phone------------------------------------ Address------- --- ------ Address------- -- - ----�----- 1--� Contractor's Name--- ----------- --- ---------- --------- ------------------------- Phone----------------------------------- Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms 3-_ Number baths __�_ Lot size ------ Water Supply: Public system ElCommunity system El Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ S y Loam E] Clay Loam Clay Adobe [:] Hardpan ❑ Previous Application Made: {If yes,date--------------------a No New Construction: Yes J No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No,septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well_____ '_Dista ce ff�pm found ti n__----- _Q_-l.MateriaL_-_.____ C� s No. of compartments--__-_ __-___! Size_P -_- I Liquid dept----_ _______________Capacity__ _ ,!__ Dispos Field: Distance from nearest well-_51-0 Distance from foundation_____-Q_--_--Distance to nearest lot line__s__-_ Number of lines__ ________ � Length of each line-------4 _ _ M Width of trench-.-� ------------------ Type ------_-________ T e of filter material____ _- r --__Depth of filter material__ Total len th_-__- Seepa Pit: Distance to nearest weli_____L_DQ ____Distance fromoundation____-_Q ___.Distance to nearest lot line-- ---------- lA Number of pits-------r --------Lining material_-- __ Size: Dia meter-___. _ '�___Depth----- �__-________ Cesspool: Distance from nearest well---------------__Distance from foundation--------------------Lining material_____-_____________-____-_____-____-_ pl ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, , Privy: Distance from nearest well------------------------------------------------Distance from nearest building-------------.--__-__-----__-------_---__- ❑ Distance to nearest lot line------- -------------------------- >------------------------------------------------------------------------------------------------------ Remodelingand/or repairing (describe)-------------------------- -------------------------------------- ---------_---------------------------------------------------------------------------- 0 -------•---------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, Stat S. and rules and regulations of the San Joaquin Local Health District. (Signed)---: -- ----- --------- ------------------------------------------------------------------- 0/or Contractor} (Title) ----- -- - - ------ --------- (Piot plan, showin� size�ocation of system in relatto wells buildings, etc., can be placed on reverse side). -FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -- --- ---------------------------------------------------- DATE---- .Z (� ----------------------- REVIEWEDBY------------------------ ----- ------------- -------------------------------------------------------------------------------- DATE-------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------- -- -- -------------------------- Alterations and/or recommendations:----------------------------- ---------- --------------------------------------------------------------------------------------------------------------------- ----------------------------------------- ---------•--------------------------- --------------------- ---------------------------- ---------- ---------------------------------------------------------------------------------- --------------------•------------ ----------------------------------- --- - -- ----------------•----------•------------------------------ - FINAL INSPECTION BY:..- `& '� 't-E'' ------------------ Date- 6- -- - -- ------- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.kaiettan Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P-CD.