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FOR OFFICE USE: --------------------------------------------------------- ----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .l. r-.�. --------------------------------------------------------- (Complete in Duplicate) � -5-/ 6/ ------ This Permit Expires 1 Year From Date Issued " Date Issued . - 1---- ----- 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. p p 5— ov—1� �,(,,0 �c_ - fU_A-if A-/7`"z fZd- 5'0,011 _6 JOB ADDRESS AND LOCATI N_ ___ ----- ------ --- 4r +► 0_ f.��C -- ---•rte-__ ____ _ 60 ----- ------------------ Phone...............--------Owner's Name -------- --- -- ---------• ----------------- - •• •.... -••--J ------------ --- --------k----------------------------------- - ------Address f Contractor's Name------ Phone Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---- Number of bedrooms ----�_ Number of baths _/_.._ Lot size _-yo-- --------------------------------- Water Supply: Public system ❑ Community system-E) Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam L] Clay Loam ElClay [Adobe ❑ Hardpan Q 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.) Septic ank: Distance from nearest well--- a__.____Dis$ance from foundation------ __________ ________________ ,7. No. of compartments--------?�7----------Sizej!_ "_-_Liquid depth----:'�_/--------------Capacity.,AP-- _.x. � Disposa field: Distance from nearest well_..rrp___.._.Distance from foundation---__J_D___----.Distance to nearest loi;line__tS____.______ [ Number of lines-----------I_______ ______________Length of each line-----.i0-----------------Width of trench----I-- -,.-_-.-----_-_--_----- Type of filter material_____ ._.-.--Depth of filter material------/1- g --- --Total length ---S¢-------------------------_ Seepa it: Distance to nearest well-----.L0.C?,.__Dist ante from foundation_;_,,__,V__r-_-- Distance to nearest lot line---��...r___.._ Number of pits.___________._______Lining material_ �.... 3_1."---- p L „� �_ Size: Diameter_______ Dept Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 2 ❑ Distance to nearest lot line- ------- ----------------------- ---------- ------------------------------------------------------------------------ Remodelingand/or repairing (describe)------------------------------------------------------•--•------------------•-••-----------------------------------------------•------------------------_ -•--------------------------------------------------•------------------------------------•-- ---•---••-----•----------•--------•------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------•--•---- ----------------•------------------------------------------------------------------------------------------------------ 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 ru egulations of the San Joaquin Local Health District. (Signed)------------------------(o� - ----------------------------------------------(Owner and/or Contractor) Pinrelafion ( tie Sy:--------------------- . •. --- ------ • ---------------•------------------ r } (Plot plan, showing sizlot, location of systeto we Is, buildings, etc., can be placed on reverse side). *. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- T -------------------------------------------------------------- DATE_;7-__` _ _6---- --------•----------------------- REVIEWEDBY------------------------------------- ----------------------------------------------------------------------------------- DATE----------------------------------------I------------------- BUILDINGPERMIT ISSUED---- ------------------------------------•-----------------------------•---------------------------- DATE------------------------------- ----------------------- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------•_--------_-------- ------------------------------------ --------------------------------- ----------- ---------------------------------------------------------------------------------------•---.--------------------------------------------------------------------•.....---------- ---------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ----I------- - ----------------------- ------------------•---- ------------------------------------ -------.----------------.--------_---------------------------------------------------.----------------------- FINAL INSPECTION BY:;// 1:�- --------------------- Date-j---�"'-;1`-�0P----.--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.tfazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Y ES 9 REVISED 8-59 3M 3-'63 F.P.CC.