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FOR OFFICE USE: �Q ---------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- (Complete in Duplicate) Date Issued _____-_.-_.- ------------------------------------- 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 Ordinance No. 549. JOB ADDRESS A D LOCATION 1 i - '� �ti �f1 G� . ---•--------- .. Owner's Name -t L{ _AC .......j .............. � _-�- L��i'" f ``-: J ------------------------------------ Phone..----------------------......=-•--- Address ........ .._ i Contractor's Name..---•----....... k CC 1 :_. {, /%t;<=��' tea.. _-.................................... Phone................................... Installation will serve: Residence [, Apartment House ❑ Commercial (Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I_ Number of bedrooms __-I. Number of baths ____L Lot size -----4-. ---X..[OjC-------------------- Water Supply: Public system ❑ Community system K Private ❑ Depth to Water Table /...Tft. Character of soil to a depth of 3 feet: Sand ❑ GravelSandy Loam F] Clay Loam E] Clay Adobe E] Hardpan [IPrevious Application Made: (If yes,date____________________) No New Construction: Yes NOW FHA/VA: Yes ❑ No, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitte if ubhe sewer is available within 200 feet.) Septic Tank: Distance from nearest w ---------j an Vr yr,d t�ii .. M er'allo. of compartments_.__ _...--____-_.__..Sized �..7� iquid depth-------- __ __:__.Capacity.-] �oDkdance from foundation ___ .Distance to nearest lot line___..... Di s os I Field: --- Number of lines eare �e ..__ /__.__ .�"_.__.. p .G. en th ofi each line______ Width of trench-- �_._.__ � 9 ---------------- Type of filter material___�-�___�- _ _ epth of filter material___--__- -------Total length........ Q________________________ 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-----------------•--•-------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------------_---------------Distance from nearest building----_._______________________------_--.... rr`` ❑ Distance to nearest lot line_----- -----------------------------------------------------------------------------------------•----------------------------------- `V Remodelingand/or repairing (describe):---------------------------.............................................................................................................................. ---------------------------•----------------------------------------------------------------------.-------------------------------...-••--------...--------.---------•••---------------.---.•--..•-------_-.------------- --------------------•-----------•-----------------•-----------------------------------•------------------•-•-------------------......................................------------------•---•-------------------------------- -------------------------------•----------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------- --- I hereby ce ' y that I have prepared this a lication and that the work will be done in accordance with San Joaquin County ordinances, e,las and sand re ul ns f the San Joaquin Local Health District. (Signe ------`-- -------- -------- ---------------------- ----- ------ ---------------------- ---- (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-----------------_-- ----------------------------------------- DATE------------------------------------------------------------ REVIEWED BY. ` � i , 'f"_. DATE----f- , BUILDINGPERMIT ISSUED-------------------------------------------------------------- ------------------ --------- DATE----------------------�a" -- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ -------------- --- --------- --- ------------------------------------------- ----- ---------------- FINAL INSPECTION BY:. Date-----------/ �----13- -_7�- � -------------- SA 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 95 9 REVISED S-59 3M 3-'63 F.P.DD.