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FOR OFFICE USE: /600,7 u� ' f r2J�tx: APPLICATION FOR SANITATION PERMIT �s s' Permit No. ..... --------------------------------------------------------- ............... --------------------------------------------------------- (Complete in Duplicate) Date Issued .41111t.11..5 _ ........-----------------.------.----.-------------------- 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 ANCA CATION---f /------- -- =': 'r�`C�.. ---- ...................................... Owner's Name ----- -- - --- ---"--- - ----r -,------"---------•-- Phone.................................... � C4� ----- Contractor's !' < fC� -----------------------•--•--------•--------•-----•---•-----Address � - Name .... I _— ..... ---...---"------ Phone................................... Installation will serve: Residence 4 Apartment House ❑ aa Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: ---I---- Number of bedrooms ----1-__ Number of baths ----I--- Lot size -------- __x_._J._C?-o...................... Water Supply: Public system ❑ Community system,K Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [X Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date----------- --------) No ❑ New Construction: Yes k] No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) l Septic Tank: Distance from nearest well_I 4-_Distanfrom foundation____ ____._..Mat r�L__ �_.�`�.:.. ,_............... No. of compartments""_a—_.------.------------Size.__`I -_x1_k__b___.Liquid depth------------�:'"":""""_Capacity../r��. Disposal Field: Distance from nearest well__/P.�V__{"Distance from foundation....�C!.......Distance to nearest lot �ne.��—___... PNumber of lines-------3------------------ Length of each line n-3n: of trench._.��: ----------------- T Type of filter material..S'7 _d_�__Depth of filter material--"_-/. __f "_-_.Total length-------- ®; Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line_-._-__________-- f ❑ Number of pits-.--------------------Lining material--------------.--------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 .".______- ..-_--________________-.❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity-.--------------------------gals. build-1-ng -- Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin ._ _________._.__.____.._. 1] Distance to nearest lot line----------------------------------------------- ---•-----------------------•------..-"-------------•------"------ ••--------"--"-------- Remodelingand/or repairing (describe):------ -------------------------------------------------------------------------------------------•----------------------------------- ................ ------------------------------------------------------------------------------------------------------------------------------------------- "--------------•-------------------------•----.-----"---------------------------- -------•-•------•--------------------------•-----"----------•----------------------•---------------------------------•-----------------------------------------------------"------•----•--------------•--------------------- -----------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------••-------------------------------- I hereby certify that I have prepared this application and that tjiIe, work will be done in accordance with San Joaquin County ordinances, St, `Aws, and rules and regulations of the San JoaquIn,Local Health District. r (Signed)_ ��_ - ll� /----- y-= ' �'� '' 2 %/'-_---------------------- ----(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---------------------------------------------------------------------------------- -- __-_-RATE_.. REVIEWED BY______________________ � � DATE.. _.. •' BUILDINGPERMIT ISSUED----------------------------------------------------------------........... ---------- DATE ---- --------------------------- Alterationsand/or recommendations-------------------------------------------------------------------------_-------•--••----------•-•--------••--•-•-----•-•-•-----------------•-••--------•- ----------------------------------------------------------------------------------------------------"......................---------------------------............................................................- ----------------------------------------•------ --••-•-----•---•--•-----------•-----•------"----------"-------------------------------------------------------•-_....••-••----••--•-•--------•---•-----------•-----•_..... ---------------------------------- --------------------•-----------------------------------------------------------------------------------------------.._•--------------------------------- --------------------- --------- ------------------ ---------- ----------------------- --- -------- --- --------------------------- -------."•-.---- 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 B-59 3M 3-'63 F.P.CD.