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FOR OFFICE USE: k _ .bk -------------------------------------------- jw led ------ ------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .11�7Z...... ------------ -------------------------------------------- (Complete in Duplicate) Date Issued --- ----------- --------------------------------------------- I This Permit Expires I 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 AND LOCATION--- J_ 2 ................................. Owner's Nam q....... - --------- ....... —-------------- ------------ Phone................. ...I......... ............ -1,1W-------- Address-1 17----------C------ .......------- ......... ...... -------------------------------------------- ....... ......... Contractor's Name------- - - ------- ....................... ------------------------- Phone................................... i" - ----------�r ; -------------------------------------------------❑*------------ Installation will serve: Residence ly Apartment House 0 Commercial Ej Trailer Court E] Motel 0 Other E] Number of living units: ___-I___ Number of bedrooms ___-_L Number of baths ....1 Lot size -----4_oe__X___X__-1 ____________ ____________ Supply: Public system [:1 Community system -M Private [] Depth to Water Table Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam E] Clay Loam Ej Clay Ey Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) Nog New Construction: Yeso NoE] FHA/VA: Yes E] Nok 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-j-&-C-----fDista fro fpundation------114-------Materl -------------- No. of compartments------�9-------------- X. ___A_.n$Gquid cleP0 .....77---.Capacity._L��------------- Size.7 Disposal Field: Distance from nearesj well_��4'-Fes_'_.�%istance from foundation.- 2- 0 Distance to nearest lot line,_��..... ----------- Number of lines-------F-------- ___________Length of each link_ -4---------?-,,,---.Width of trench......0---------------_---------- Type of filter material---- epth of filter material----- ----------------Total length------12 ------------------------ 7F- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits__ _________________Lining material-------------- --------Size: Diameter_.--___.__.___.___._._.Depth_--__-.__--__---.________________ IZ3 Cesspool: Distance from nearest well-----------------Distance from foundation.--_--------------Lining material__-_--_---_.__-__._.--___.----_____-_. 1 ❑ aterial------------------------------------- F1 Size: Diameter---- ------- ------------------Depth---------------------------------------------------Liquid Capacity----- gals. Privy: Distance from nearest well_________________ _ ____ _____ __ __________Distance from nearest building.____---__--_-_-______----__--___--_-.-. ❑ uilding------------------------------------------ F1 Distance to nearest lot line Remodeling and/or repairing (describe):-----/19 ........... ----- ......... -------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ ------------------- ---------I--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- --------------------------------------------------------------------------------------------I-----------_---------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules regulations of the San Joaquin L al Health District. (Signed)------- ... ....... 'S- -------- ----------------------(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--------------------- ---------- ---------- ------------------------------- ------------- DATE------ - ----- - - - - - ----------------------- --- REVIEWED ATE------ REVIEWEDBY--------------------------------------------------------------------------------------------- DATE------ ----------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- DATE--------------------------- ----- Alterations and/or recommendations:_---_----------_----------------------------------------------------------------------------------------------------------------------- -----------------------------•------ ---------------------------------------- ---------- -----------------------------------------------------------------------------------------------------------------------............. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- -----------I------------------------------ ----------------------------------- -------------------------------------- ----------------- ................. --------------------I--------------------------------------------------- ---------- ------------I------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY%.----------------- ----------------------cry-''--------- - Date-------------------��/ �'`�` SAN ate-------------------- 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.120.