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FOROFFICE USE: ------------------------------ -------------------------- ----------- --------- ------------------------- -------------------------_____________________________________________._. APPLICATION FOR SANITATION PERMIT Permit No. . ..? . -------------------------------- -------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ____..l_/�� 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 LOCA ION.-,r...R-0S....967-------I� &T� E---�__ 1�J---=------ �f _VA U11 ,---- ---------- Phone-------------------------- ..Owner's Name_ ��/V..__�_- � --_-_ -- Address---------------- Qp��........ �.. Contractor's Name_____Q.WN-Fp--------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial '0 -`fr'aller Court ❑ \Motel � Other 1 y-Rf}i►-ir Number of living units: _�____ Number of bedrooms .-�___ Number o aths --1(_--- Lot size ----- �7�__��.0....................... Water Supply: Public system ❑ Community Sys •❑ "'Pri'vcte" Depth to Water Table Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay.❑ Adobe ❑ , Hardpan ❑ Previous Application Made: (If yes,date---------- ) NoNew Construction:,.Yes., atA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well---?-__---Distance from foundation----//--______-Material , p_____---_ No, of compartments-------'.�----------Size.�x_�_x ��___-Liquid depth__:_--- ----------------Capacity------ ��-- Disposal ield: Distance from nearest well....757Distance from foundation-----j0........Distance to nearest lot line______. Number of lines-----------/---------------------Length of each line------ ---- ............Width of trench-------0�t-`/---------------- Type _____-_-__-__ T e of filter material___R-05;/<s 11 yp .____Depth of filter materFal______� __-.. -Total length__________�0-______________________ Seepage Pit: Distance to nearest well--------------_-------Distance from foundation....................Distance to nearest lot line___-___--___-____ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Dept h-------.--------.----.----------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material._.--__________-________-----__-_____. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------- ----gals. Privy: Distance from nearest well______ -----------------------------------------Distance from nearest building_______._____________________-__._-__.._. ❑ Distance to nearest lot line------------------------------------------------•------------------------------,.. Remodelingand/or repairing (describe);-------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- --------------------------=•----•--------------------------------------------•--•---•-•---------------------------------------------------------•-------------------•-----•-----•-----------------------•------------------ --------------------------------------------•---••----------------------------------------------------------------•---.. -------------------------------------- -------••-----•------- --------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws a�nrns of the San Joaquin Local Health District.(Signed)---------- G -------------------------------------------------------------------------- ------...(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------- i REVIEWEDBY.------------------------------------------------- -----------------------------------•--------------------------------------- DATE------------ BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------ Alterations and/or recommendations-------- --------- --------------------------------••--------_---------•--------------------------------------•-•--•-------•-••-----------•----•-------------- ------------------•------------•--------------------------- -•-------- -------------------------•--------------------------------------------------••-----.-....- ------.--•-------------•-•-------------.-.--------- FINAL INS TION BY ---- ---- --- - - Date-----------1--- �/ T { . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 20S West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 REV48ED 9-59 F.P.r P,2.6.60