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FOR OFFICE USE: --- ------------------- -- - ---- ------------------ -------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .................... (Complete in Duplicate) Date Issued --- ---- ------------------ -------------_----------------------- This Permit Expires 1 Year From Date Issued 00"r- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her in describer!. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND OCATIO 3l� ?�' lcr� K '-- '" '- a---------------- Owner's Name------ w-------- ------- ------1- --- -- --- ---- Phone----------------------------------- Address------------- --;------ ------------- -------t---------- ------C---------...------------------------------------ o Contractor's Name.. :. -+ - -------- Phone...- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other (�—, / Number of living units: -1----- Number of bedroomsoZ--- Number o baths -i-.--- Lot size .----.--- _-_- -- - ------------------------------ Water Supply: Public system E] Community system [-] Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) c Septic�Yank: Distance from nearest well.-.3-9- _----.D' t c from foundation--_-/0--------Material-------�-14-11��. _d-------------------- [( No. of compartments---------�_----------Size- --' ."; -x�_------Liquid depth----V-------=----------Capacity--Leo-Q- a �` Dispos�i Field: Distance from nearest well from foundation./I22 to nearest lot Number of lines-------- ---------------------Length of each line----S -- -------------Width of trench.- -- -------------------------- Type of filter material.----5- --/2--------Depth of filter material----.-/Q-- -----.Total tlength-_.-/.-C--c7- ------------ -------See --------- foundation Number of pits----.-/-------------Lining material-S-t>?-------------Size: Diameter------33-"-------Depth---QR-S'1--------------- [ , Cesspool: Distance from nearest Weil-----------------Distance from foundation------------------- Lining material------------------------------------- 171 Size: Diameter------ -------------------------------Depth--------------------------------- ------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----_-------------------------------------------Distance from nearest building.----------_._--------------------------. } ❑ Distance to nearest lot line-------- --- --------- Remodelingand/or repairing (describe):--------------------------------------------------------------------------------- --•------------------------------------------------------------------. -------------------------------•---------------------------------------------------------------------------------------------------- -----------------------------------------------------•--•-------------------------- ---- ----------------------------------------- -------------------------------------------------------------------- ---------------------------------•----•----------------------------------•------------------------------------ -------------------•---------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and regulations of the San Joaquin Local Health District. FZ (Signed) - --- -------------- -- -----k --- - --- ------------------ --------------------------------------------------------------------------- and/or Contractor) By:------ t ---------------•--------------------------------(Title)---------------------- ----------- --... ..-------------- (Plot plan, showing size of of, ocation of systemi relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. - :"� -- ------ ---------------------------------------- DATE--4(--- -------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---------------------------------------•--•-------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------ ----------------------------------------------------- Alterationsand/or recommendations--------- ------------------------------------ ------------------------------------------------------•----------------------------------------------- ------- ------------------------------------------------------- ------ --------------------------------------------------------------- -------------------------------------------------------------------------------- ------------------------------------------------ -------------------------------------- ------------------------------------------------------------------------- ---------------------- --•------------------ -------- FINAL INSPECTION BY:..-- . � ----- Qate t -- - --- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 REVISED 8.59 3M 3-'63 F.P.CO. k