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FOR OFFICE USE: d J�ln�l� r APPLICATION FOR SANITATION PERMIT . --- ----------------------- ------------------------ Permit No. ... __ ----------------------------------------- ------------ (Complete in Duplicate) a r -_..____________----------------------------------------- This Permit Expires 1 Year From Date Issued 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 OCA ION1 ' �( ...............................`1 .��.t � C � :�-------------------------s -_ � Owner's Name_ ------------`-�� -" � Z hAddress_.__.=-9-r`�••—IX-- -=----------•--- � -�--- L_cf__ _ �.-----------t ri =1j�---�� Contractor's Name.........` =t`'={ =1" -------------------------------------------------------- ----------------------------------•--- Phe.--------------------------------- Installation will serve: Residence [�f\Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I-- Number of bedrooms ---4 Number of baths ---/- Lot size ___�__X--J-o U Water Supply: Public system ❑ Community system a Private ❑ Depth to Water Table JJ'_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay�Adobe❑ Hardpan Previous Application Made: (If yes,date-----------:--------) No 0 New Construction: Yes ❑ 1 No FHA/VA: Yes ❑ No ✓ TYPE OF INSTALLATION AND SPECIFICATIONS: Y�, � v`c p (No septic tan or cesspool permitted if public sewer is available within 200 feet.) Se ti Tank: Distance from nearest well __- - _Dista f� .jq-�------ depth t rl_ -____ Ca acct __jr-------------- PR No. of compartments__-_/ _-----------------Size___ -________ W q ,s P Y Disposal Field: Distance from nearest well---___` _Distance from foundation_____ _______-Distance to nearest lot li � `_'._._.____. d Number of lines_-__ a_____�;�--______--___Length of each _;_ ------ �__-Width of trench___-�� ________________ 1 Type of filter material-r. �_��_'&-__Depth of filter material____-_ �k___ ____Total length-------------!ii_o.................... 4 Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_____-___________ d ❑ 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-----------------___...................-_. e ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- / Remodeling and/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, ate, laws, and rVIjes and regulations of the San Joaquin Local Health District. (Signed]--,- _ �_ e�1 ._.5'_ ��_'r't / ________ _ _______(Owner and/or Contractor) rq _ ___ _ ____ _____ __________________ ___________________ __________ __ By____________ _____c__�_F_______ .` . .?`-___________________________-_____________________________________________(Title)__-______--___--_____________--__-_------ . _ ----.______. l (Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc., can be placed on reverse side). 1b FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------- ------------- --------------------------------------------- ,_.- _ DATE----------- --- REVIEWEDBY------------------------------------------------------------------------------------- DATE........ /- -' ----------- BUILDINGPERMIT ISSUED-----------=--------------------------------------------------------------- ----------------------- DATE-----------------------------------------------------•----- r ,Aktoations arfc�/ r ria a dations: _____________ ______ --- ___ 9e n. -- � � - � -------------------------- ----- -------------- • ! Jk -•• —.... ' ------- � - •-------- -- ---------- -- -------- ------------- -- -- --- _ - -------- .................. ---------- .................. ----- --- FINAL INSPECTION BY------------------ ------- ----------- Date------- -------- -- ------------------------------ SAN ---- --------._.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 ES 9 REVISED 8-59 3M 3-'63 F.P.CD.