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FOR OFFICE USE: qft d;? (p vie "I 2, 11 _ff APPLICATION FOR SANITATION PERMIT Permit No. ...,1. �. -------------------------------------- --------- -- - (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. ' ��-� �Ci JOB ADDRESS AND j.,OCATION---- -- - --.. ------_---- Owner's Name----- Q ' 'mac'` `� -------- - ----------- Pone Address .o .t ------- z.. --•------------- - < ► ------------------•-----•--. Contractor's Name---------------a Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __1----- Number of bedrooms ._K� Number of baths __I--- Lot size ..5.U__-•---1-4fO------------------------------ Water Supply: Public system ❑ Community system ❑ Private [6 Depth to Water Table . __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Previous Application Made: (If yes,date____________________) No 9�, New Construction: Yes [�( No ❑ FHA/VA: Yes ❑ No 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�k-_--__Distancg from, founds ion-__1.0__•--_-__.Ma er�aL_ _____ � _ IIA No. of compartments_------ ' _-t Liquid depth_.- - �___-___Capacity...I�_��. G G Disposal Field: Distance from nearest welly=_ �-__Distance from foundation. Distance to nearest lot line ` Number of lines-----*2kf______ ___ -. Length of each line x`?.`" + Width of trench. __�.>.�. ___ r- Type of filter material. __Depth of filter material.._._________Total length...... _._4................ Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 171 Number of pits______________________Lining material-----------------------Size: Diameter----------------_......Depth__--.-_-_______:___--_______--- r Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--__---..____--__-___._.________.__.-. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity--------_----•--------_-gals. Z Privy: Distance from nearest well----------.--------------------------------------Distance from nearest building-------------------------------............ ❑ Distance to nearest lot line------------------------------------------------------------------------------------ ------ Remodelingand/or repairing (describe):------- -----------------------------------------------------------------------------------------------------------------•__----------------------------- -------------------------------------------------------------------------------------- -------------------- ----------------------------------------------- ------------------------------------------------------------- -------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------•--•---------------- 7 I hereby cert' y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules anereulafions of the an Joaquin Local Health District. / lV(Signed)_.._ . . .._. Gsf. rte-_ .--- ----= (Own and/or Contractor] . ... -�---- --------•---.--- �y__,0--------------------------------------------------------(Ti tle) ------- (Plot --- - - ---- Ely:_ (Plot plan, s owing s' a 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------------- ---- ----------------------------- REVIEWEDBY--------------------- ------------ ----.------------------- --------------------------------------------- ATE,[ ' BUILDINGPERMIT ISSUED------------------------------------------------------------•---------_---------------,/------------ DATE--------------------------------------------- -------------- Alterationsand/or recommendations------------------- ----------------------------------------------------------------------------------•-------------------------------------------------------- ------------------------------------------------•--------•--••--------•----------------------------------------------------------------•----------------------------------------------------------------------------------- ------------------------------------------------------------------------- -----------------------------•--------•-----•------•---------•------•----•---•----•---••------•-----------•-----•------------------.--------------- --•-------•--------------------•-----------------------•---------------------------------------------------------------------------------•------------- ------ --------------------------- ---------- ------ ------------------ ----------- ------------------------------------------------------------•---------- J - FINAL INSPECTION BY-------- -------------- ------- _---- �� -------- - Date------/2...............---------------------------••-•------••---------• 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 99 9 REVISED 8-59 3M 3-'63 F.P.CD.