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FOR OFFICE USE: --------------- ----------- -------- --------- 1<e --� --------------------------------------------------------- APPLICATION FR SANITATION PERMIT Permit No. ..�.9.1rr1_ ------------------------------------------------------ -- (Complete in Duplicate) �7�6 - ---.._---- ----------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -7/7...................... 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. 519. JOB ADDRESS ND LOCAT N.. t A ��0 e Owner's Name. ----------t----- --•. •-•---------... ... � Phone Address..................�-y-- -------- . .--------�(� �� Z-- --------------------------------- Contractor's Name-------------- ----------------- -- -.............................................=...................................... ............. Pho Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑"Other ❑ Number of living units: --I----- Number of bedrooms -VNumber of baths --------(Lot size Water Supply: Public system ❑ Community system X- Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loan)X Clay E] Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date_______________.-__) No-A New Construction: Yes �`\No E] FHA/VA: Yes [-] N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank: Distance from nearest well je66�I"Distanygfro�j ound yen_-.__j_-C)---.-_.M ------- h No. of compartments------' �-------------Size__!{_L_---.�-.1---_-- -. _-Liquid depth__.�_C..�__._Capacity..,�-2-— Disposal Field: Distance from nearest well_ Q®.�7istance from foundgtion. ?________.Distance to nearest (ot))il�„ (\,, Number of lines-�-----------------------------Length of each line-&P-6-0--l-f- of trench._o—Ze--` ----.----_-_.--__ p Type of filter material------------------------•Depth of filter material---.-___.-.__.__---__-.Total length.......................................... 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---._------__-_____---_---_-____---.- 'r ❑ Size: Diameter--------------------------------------Depth-------•--------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------- _ ._ -__. --_-- _____-_.-Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line----------------------------------------------------------•------------------------------•-•---------------------------•---------------------- Remodeling and/or repairing (describe)------------ • --------------------------•----------------------------------------•----------------------................................ ----------------•---------•-----------------•------••-----------------•----•--------•----------------•---•-•------------------•------•---------••------------------------•--------•- •--- ------ ------------------------------•----------------------.----------------------------------------•---------.---...--------------------•-•-.------..------.----.---.-------..-------------.----.-------------------------------- ------------------------ -------------------------------•---------------------------------------------------------------------------•-------------------------------•-------------------------------------------------------- I hereby ertify that I h e pre re this application and that the work will be done in accordance with San Joaquin County ordinances, S to laws, and e I n re tions of the San Joaquin Local Health District. ------------------------Owner and/or Contractor (Signed)-�' -----------------------------=---------------` ------------------------------------------------------------------------------- ( / ) 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 APPLICATIONACCEPTED BY---------------------- --------- ----------------------------------------------------------------- DATE------------------------------------------------------------ REVIEWED BY----------------------------------------------------------------- ------ ATE---- - 1------------------ ---------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------- DATE Alterationsand/or recommendations--------------------------------------------------------------------- ----------------------•-•-----------------------.----------------------------------•-- ------------------------------------- ---------------------•......--------------------- --------- ---------------------------------------------------------------------------------......................................... ---------------- ------------------•---------------------------------------------------------------------------------................................................. ------------------------------------------------•--- --------------------------- --------------------•--------------------- -------------------------------- ----------.------------------.-•---------------------------------------------------- -------------------------- ------- ------- --------------------------------- GJ' 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 ES 9 REVISED S-59 3M 3-'63 F.P.CD.