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FOR OFFICE USE: rn ` �✓ „�. _ (/' as I _ i .................... APPLICATION FOR SANITATION PERMIT Permit No. ... ---------------------------- ----------- -------------- 0 _ ------------- ------------------------------------------ (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 AND L CATION_- �--------------------- - -- '---------�' .!_ �� -C-t----- fr Owner's Name._ ----- ----------- r--- --- --------------- Phone -- - Address---------- 1,.cf �t_trF � - -` 1 - ._ k -------------------- Contractors Name . ........... Phone. Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court [1 Motel ❑ Other [3t 4 eV Number of living units: _!..... Number of bedrooms ......-Number of baths ---t--- Lot size _ _ -------- f,&_,-a________________________ Water Supply: Public system ❑ Community systemPrivate E] Depth to Water Table fZ7- Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam 1771 Clay [ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes No ❑ FHA/VA: Yes ❑ N ] 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 `-__Disfen ( JJ �f{ fodation_____ .......Mt e(al______:`r unZy ----------------------- -- 4r{- � f .:--Liquid depth_ __ ______- pauty__No. of compartments_______-)'____--__-_-__Size. -___ Disposal Field: Distance from nearest well------'---..Distance from foundation---_�_1- ___ _.Distance to nearest lot-1 fr�e_ ____. Number of lines_..�. ----Length of each line- ---Width of trench. < Type of filter materiah _.L- �: -' _ Depth of filter to • �___.__-_Total length.-J.11................................ Seepage Pit: Distance to nearest well-------------------=._Distance4rom fo"n a- io Distance to nearest lot line__________.____-_ Q ❑ Number of pits----------------------Lining, material___ _.�"_ __40-SI a:meter-----------w---------Depth--------------------- ----------- 0 Cesspool: Distance from nearest well_________________Distance from foundation___-__________-_.Lining material-------------------------------------- G ❑ Size: Diameter----- ------Depth---- --------- ----- ---------Liquid Capacity --------------gals. Privy: Distance from nearest well_____ ________________________ Distance from nearest.building.----------------------------------------; ❑ Distance to nearest lot line---------------------------------------------- ----------------------------•-----•• --------------------------------------------------- Remodeling - -• ----- -------- ----------------- -Remodeling and/or repairing (describe):-------- -------------------•--•- --------------------•---•----------------•-------------------- •--•-------------------------Q -----••-•----•-- ---•----------------------•------•----•---------------------••----------------•------------•-------------------------------•----------- ---------•--•-----•--•----------------3 -----•------•--•-----•----•--•------------------------•---------•-•----•-------------------------------------------------------•------•-•---------------------•-------•------•-••---------•------•---------•---•--•--- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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, Aw (Signed)-------- t L'R" 1---- ---- , '-C- -------------------- - ----------- - -- ---------------------- -------- ----- --(Owner and/or Contractor) BY: �t:--------- ,� =/�'--------------------------------------------------------=----------- (rifle) - i (Plot plan, showing size of lot, loca to of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------_-------------------------------------------------------------------------------- DATE----- —-- ------------------ REVIEWEDBY---------------------------------------------------------------------------------------------------_--)_ . -; _ DATE---- --------------------------- BUILDING PERMIT ISSUED - ------ '-----_. DATE------------------------------------------------------------ Alterationsand/or recommendations:----------------------------------------------------------------------------------------------•--------------------------------------------------------------- -------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------•----•------------------------------- -------------------------- ---_------------------ -------------------------------------------------------------------------------------------------------------...........................................---------- -------------------------------------------------------•-•-•------------------------•------------------------------------------- ------------------------------------•------................................................. 1_ 6 i FINAL INSPECTION BY--------------- /� -.�'- Date------------ ------ SAN 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 96 9 REVISED 8-59 3M 3-'63 i.P.CD.