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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----- --------------------------------------------------------- -__----------------------------------------- ---- (Complete in Duplicate) _ lv ci __________________________________________ -------------- This Permit Expires 1 Year From bate Issued Date Issued .--3.--_-- --{ 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 No. 549. JOB ADDRESS.AND LOCATION- 2... 2------ %%� ` --- = = --------------- Owner's Name �- s ------ Phone- �� !=: Address----- /. , v'R 2 Contractor's Name- J f J� 7 �' "� `� ---\\\1•--- L f _U------- Phone----•--••--••-----------------•---- Installation will serve: Residence "artment House ❑ Commercial ❑ Trailer Court [J Motel ❑ Other ❑ Number of living units: ---�---_ Number of bedrooms ---1--- Number of baths _f__._ Lot size ._ '/J� _.` ' !---------------__.---_.-_-_ Water Supply: Public system ❑ Community system ❑ Private ['Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes O`No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s C� / R-�Q Septic Tank: Distance from nearest well___ ____Distance from foundation____�_ __--..__Material -- _.______--_------_--.- 2� No, of compartments______---.-_�-.--._Size___ _. ____ - -Li Liquid de th--__-__. -__�._-----.Ca p acit � � Disposal Field-. , Distance from nearest well..- 'f ..._Distance from foundation_____l_I71____.Distance to nearest lot [� Number of lines----------------_�---------------Length of each line----------- �------- of trench---.--�-�_ -------------------- Type ------------------- Type of fi#ter material____._/L'2__d_�__0-Depth of filter material---IX---"1-----._Total length..........�_'O----------------------- Seepage Pit: Distance to nearest well-----_----------------Distance from foundation-------------------.Distance to nearest lot line--.---_---.----._ [] Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- Size: Diameter---------- --------------Depth ---------------- - ❑ P - - ----------------Liquid Capacity------------- -- -------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_---.-----_-__________---__--.--_-_--- ❑ Distance to nearest lot line-------------------- ------------------------------ -------------------------------------- Remodeling and/or repairing (describe):---------- - - --------- -----_ - __ -_-_-•JJ ------------------ ----- ----- --------------------------------------------------------------------------------------------------------------- -------------------------------------------,___-_-_.-.__-_--__-_.___.--..-_---___----_-_-_-____-----______-____—� - --------------------------------------------------------------------------------------------..._.-_-_.......- 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, aqd rules and regulations of t Sa Joaquin Local Health District. S (Signed};�----------------• -- - ------�--------------------(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 APPLICATION ACCEPTED BY------`!C-- -------------- -- - �f --- �------------------------------------------ DATE------�-- --y�-----�� REVIEWED BY -- --------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and or recommendations---------4 __.z :z-/.6_.`�:._..------(a_-_-�-.--___ (�-- Yom-L -- p_ �I _ ------------ �J----.4— C-c---- -- - -r-7� '"�"`._�- - .-�"�--'-------+ -�<----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------ - -- - - -- - -- --------------------P --------.----------------------.----------.-------..-----------..____.__.._...._____.-.-__.------_.-_----__----..-.----- FINAL INSPECTION BY--------------- ----•--------------------- ------ ------------- Date----------------------- ----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD.