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FOR OFFICE USE: �,e / 2r --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .17..7 -------------------- -------------------- --------------- (Complete in Duplicate) Date Issued A.0*_.V. ______________________________________________________ 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. v� t JOB ADDRESS AND LOCATION__ / tltz j_ ��,C ___ `_1!_ Y. Ltl _-_________ --_ Q -------1!!: Owner's Name---- e W_t--- .ty -•----------------------•--------------------------------------------------------------- Phone--7,4 Address................................................ -------- ------------- - ti _ Contractor's Name -- ' s �,---- Phone_._ `'! ' - , Installation will serve: Residence [��Apartment House ❑ ommercial ❑ Trailer Court ❑ Motel ❑ Other�] __l} '— o Number of living units: ____ Number of bedrooms __ _ __ umber of baths __/__ Lot size __s�_____.._..°�.___��_Z__��_ ______------------ c) Water Supply: Public system F-1Communitysystem Private [:] Depth to Water Table __....._ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (if yes,date----_---------------) No ❑ New Construction: Yes ❑ No V,-fF A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 5 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tic rt : Distance from nearest well_________________Distance from foundation--------------------Material-_---_--_______-_-___--_-______--_-.,-_.-_____. 1W No. of compartments--------------------------Size--------------------------------Liquid depth----------------- --------Capacity----•------ V DWosi Distance from nearest well ).: ._._Distance from founds ion___ ___ .Distance to nearest lot line_._________ Number of lines.__.__.__ _._ Length of each line__.�L? i Width of trengh____a2_ _____ _______________De th of filter material_ ___... ��_.Total ren th btL'�°_.__ __________________Type of filter materia{ __ st.- K1 g - Pit: Distance to nearest well_.s___________________Distance from foundation__-__._____________.Distance to nearest lot line__-__--__--___-__ Number of pits----------------------Lining material...--------------------Size: Diameter------------ Depth--------------------------------- Cesspool: Distance from nearest4vell-----------------Distance from foundation-----i--------------Living material-------------------------------------- tO ❑ Size: Diameter---------------------------------------Depth----------------------------- --------_-------------Liquid Capacity.........................---gals. eP.- Privy: Distance from nearest well --.___-________________-----------------------Distance from nearest building------------------------------------------ G ❑ Distance to nearest lot line---------------------------_------------------------------------------- coG fl. Remodeling and/or repairing (describe) _. ____ _ __ _ ----__ _ ____ ________ - - •• - ------------------------- - ---- � �---�-------- . ' � - ------------------------•----------- ----------_-----•----------•--------- --- •-•• --------•--- ------------------------------- ------------------------•-------------- --------------- fY ------------•------ ----------------•---------------••---------------r ---•---------- ------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance tate I ws, and rules and regulations of the San Joaquin Local Health District. 1 (Signed)---• ---------- _ --- (46W �r Contractor) V, __...Title BY: Y 9 p ) (Plot plan, showing size of lot, location of system in relation to wells uildin s, etc., can be laced on reverse side). FOR DEPAPMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE--------_------------------------------------------------- REVIEWEDBY---------------- , ..------------------------------------------------------------ DATE--------.--------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------- -------------------------------------------•----------------------•--------------------------------------------------------------. ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ----------- ------------------------------- ---------------•-----•---------••-•------------ ------------------------------------------------------------------------------- ------ --------------- ----------- ----------------------------'=---------- FINAL INSPECTION BY:.___..__._._..________ ______ f Gt=' --=--•1---------------------- 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.