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FOR OFFICE USE: ' --------------------------------------------------------- -------------------------------------_---__--.____--_- I APPLICATION FOR SANITATION PERMIT Permit No./4T .......... --------------::-:,---------------- --------- (Complete in Duplicate) je ----------- -........I------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued30__ 3 Application is hereby made to the San Joaquin Local Healfh District fora permit to construct and install the work herein described. This application-is made in compliance with County Ordinance No. 549. JOB ADDRESS A D LOCATION �f ! ------ - -�-- _�__ Owner's Name `- 1 '• �1 c t. [- -------------------------- Phone--- •------- ---------------------------------------- -----------.:------------ -----------------•-------- Contractors Name--------- _ ' t•-•-- -- -------- --------------------------•----------------------- ------ Phone-------------------------------- Installation will serve: Residence ❑ Apartment House.❑"'Comrnercial .l]-Trailer Court ❑ Motel ❑ Other [E- Number of living units:. ----..-- Number of bedrooms ----._ Number of baths -------- Lot size Water Supply: ',Public system E] Gonlmunity;system`0` Private [Depth to Water Table _-29U ft. `Character-of=soil to a deptli'of'3 feet:- Sand ❑- Gravel ❑ Sandy Loa m❑ Clay Loam ❑ Clay ['Adobe ❑ Hardpan ❑ Previous Application Made: (if yes,date--------------- -- ] No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool'permitted if public sewer is available within-200 feet:) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material__________-._______--.___.______.___-.__-______. ❑ No. of compartments--------------------------Size---------------•------------I---Liquid de ,th_---------------. ---- - Capacity Dispos9J�Field: Distance from nearest well.... 5?-_r_._'Distance' from foundation------Lt)--------Distance to nearest lot line------ 6-------= -�'_--Length of each line------10.0-.`-----------.Width of trench----- x`-�------------ ---- m Fill Number of Tines------------ - ----- R._....Type of filter material__�'_�.�___`�ylJepfh of filter material__.__1�'_��_..___Total length________.�_�_4_�__ _ -� :� ------------------ Seepage Pit: Distance to nearest well__,.....!¢a_. ----Distance from foundation______ --e -- to nearest lot line-.s--------- Number - --__Number of pits-.---- J----------Lining material___-S'.,e- -------Size: Diameter--------�Ve"'-----Depth----- 9- -'S'- ----------------- } Cesspool: Distance from"nearesf well-----------------Distance from foundation---------------- material__---__.-._------_..__-.-____.___i ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity------------------ gals. Privy: Distance from. nearest well------------------ -----------------------------Distance from nearest building.__.__--____._--_________---_.. l❑ Distance to nearest lot line - ------------------------------------------------------------------------------------------------------------ - �I Remodeling and/or r pairing (describe]----------------------------:-----------•------------------_--__-_-------_ ------------------------------------- f ----- ---- -- - ---- ----------- - - ------------------------•-------------•-----------------------•---------------------------- --- ---------------------- n I hereby certify that I have prepared this application and that the work will be done in.accordance with San Joaquin County r ordinances, State laws. and rules and regulations of the'San Joaquin Local Health District. R r 7 � c a (Signed)---------- -_ ---- -- ---- -- - ---- -- -��z----- r(flwrreran / r Contract Y: s� - y Title p = ---- ---( ) ------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). , f FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY -- _ DATE__ � �: �.� " REVIEWED BY--------------------------------------------- -------------------- ---------------------------------------------------------- DATE---- -- --- --------------------- BUILDING PERMIT ISSUED-------------------------------------=----=--------------------------------=-----------------------. DATE Alterations and/or recommendations:__-------------- ----- - ---------------------------------- r1 --- ----------------------•----------------------------------------------------------• -----------••----------------------------------------------------------------------------------- ------------------• ----------- ----------------------•--------------------------------------------=----------------------- ------------------------------ FINAL INSPECTION BY:--- -.. 5 Dafe- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Sheet 124 Sycamore Street'- 205 West 91h Street Stockton,California Lodi,California r'Manteca,California Tracy,California C5 9 REV45ED E3-59 'AM 3-'63 f.P.CD. i"