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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ../--------------------------------------------------------- - ----- ---------------------------------------- - (Complete in Duplicate) Date issued -----� ----./c- ----------------_:-------------------__----_------------- 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 County County Ordinance No. 549. Q,5`:3 — (030 — 2- JOB ADDRESS AND LOCATION.--�-=`-'- ------------- -- _..---•- --- ----------------------- ---------------------- ./ � � Owner's Name---------- -.��._-.�_..---- ----- - ---�---�s�----- - Phone------------------------------------ Address............ ------------- ----------------•---- Address------------ f Af e� ' `-'`A'------------- Contractor's Name--- ?2'a' ----= -----------------------------------••---------- ------ Phone-------------------- Installation will serve: Residence ']. A artment House ❑ Commercial ❑ Trailer Cour# ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms __!q__ Number of baths _y_ Lot size __, _ _ __ _ _______________________________ E Water Supply: Public system E] Ctommunity system ❑ Private,[B Depth to Water Table _90 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loamjn Clay ❑ Adobe ❑ Hardpan, ] Previous Application Made: {If yes,d,ate---------_---_ } No E] New Construction:- Yes .❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank,pr cesspool permitted if public sewer is available within 200 feet.) ; moi' 1 , Septic Tank: /26isf,ince from nearest well---�c7------Distance from foundation----b----------Material__1��-------------------------- r, No. of compartments----- ----------------Size_g4`_—i!?t.s---------Liquid depth------#................Capacity-_e4,07A------ a Disposal Field: Distance from nearest -------Distance from foundation-----,/_0---------Distance to nearest lot fine_`..__.__... ® Number of lines_____ -------------------------Length of each line-----/q7b�--------------Width of itrench. ,_____________________ th___. _- Depth of filter raterial___. -'____-__dotal len _ __:_____________________._TYpe.of_flter materiaj/.4'� Seepage Pit: Distance to nearest well-----j�_______Distance from foundation----�Q_'' ..Distance to nearest lot line_,<----------- 9 J Number of pits---_ Lining material --------Size. Diameter.-�� -------- ---------------- Depth_.r --------------------- Cesspool: Distance from nearest well--------------___Distance from foundation_--------------------Lining material_._._.._.____.______.____________---. ❑ Size: Diameter----:--------------------------- ----Depth--------------------- ------------------------.-----Liquid Capacity---------------------------gals. Privy: Distance from nearest well___---_----_-------------------------------------Distance from nearest building_----___------------------------- _.--_. P [� Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------- i Remodelingand/or repairing (describe):--------------------------------- -------------------------------------------------------- -------------------------------------------------------- 3 r ------------------------------------ -------------------------•-•--------------------------------•----------------------------••--••-----------------------•------------------------------------------------------------ --------------------------------------1-----------------------------------------------•-----•------------- ------------------------ ------------------------------------•-------------------------•------------- 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. i (Signed ---------� l -------------------------------------- ----------------------------------------- ---(Owner and/or Contractorl SY:-------i-------------------------------------------------------- -----------------------------------------------------------------(Title)---------- -----------I--------- - ----- - - ------- (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reyerse side). , FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY-.. ?'a-�i�l !.! DATE_ a -----�-------------------------- REVIEWED BY----------------------------- -------------- ------------ --------------------- --------------------------------------------- DATE--•--------------- ---- --------------------------------- BUILDINGPERMIT ISSUED---- -•------------------------------------------------------------------------------------- -- DATE--------------------- Alterationsand/or recommendations-----------------------------------------------------------------------------------------------•--------•-------------------•--•------------------------------- -------•-------=------------- ---------------------------------------------- -------------------------------------------------------•----•--------------------------------- ------ ---••----••-•-•-•---------- ------------------------------------------------------------------- ------------------------------------- -----------------------------------------=------------------------ ------ -------------------------------------- -------•------------------------------------------------------ ------ -___--------------------------------------------------------- ------•--------------------------------------------------------------- --------• i FINAL INSPECTION BY:,,�&_,_4 ----------------------------------------•--•---- I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. , 300 West Oak Street 124 Sycamore Street 205 West 91h Street i Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 32'63 F.P.CD. - - rt