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FOR OFFICE.bSE: - APPLICATION FOR SANITATION PERMIT. Permit No. .__ ...f.�--�r�/ --------------------------------------------------------- -------------- -- ---------------------------------- (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. B ADDRESS AND LOCATION- � ------•------ JO C G !1 Owner's Name UC%Q' -� -----------•- Phone t < Address /l �_G. .. !1��- t ----- ---- -- - Contractor's Name----- J-i. -;-5_ -----------------•--•---------. Phone-------------------""------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___k Number of bedrooms-3.... Number of baths _f----- Lot size7` -------------------------------- Water Supply: Public system n---c-ommunity system ❑ Private ❑ Dep+ to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 0# Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No Pr-_-New Construction: Yes ❑ No [!J'FHA/VA: Yes ❑ No [r' TYPE OF INSTALLATION AND SPECIFICATIONS: r --..(No.(No septic tank.or-cesspool permitted if public sewer is available within 200 feet.) T - r Septic Tank: Distance from nearest well---- Distance from foundatioruff_-_------------Material' ""-90- _-__._._._____.___ .___.__""""_". No. of compartments- . __.____--- Size_- ------Liquid depth= s---------Capacity---dz- Dispo� Field: Distance from nearest well------'—'._Distance from foundation"/b-----_---_""".Distance to nearest lot line�J�_.___.... Number of lines___�------------_-------------Length of each line_csa-f----------------Width of trench ______.______-...- H Type of filter material____&_GX-------Depth of filter material_/_.g--------------- length-----1.4-13.....----------------------- � Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line____._._....___._ [] Number of pits---------------------Lining material-----------------------Size: Diameter----------_--Depth----------------------------"""-- 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):--------------------------------- --------------------------------------------------••---------•--------•-----...-------------------•----------------- d ------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------I-----------------1"O ---- ---------------------------------------------------------------------,-----------------------------------•-------"----------------------------------- ----------------------------------- ------ - ---------------------------- 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 and r gul ions the San Joaquin Local Health District. (Signed)--------------------------- ---------------- ------ - --- ---------------------------•--------------------------------------------- -----------._.(Owner and/or Contractor] By:------------------------- ---- ----------------- --------------------------------------------------------------------(Title)----------------------------------------------- f --------------------------------------- -- --- (P1ot plan, showing size of lot;location of'syst m'in refatian-to wells, -buildings, etc., can•be placed on-reverse.side). - _ __-- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -0 ------- --------- DATE--------.6.40_- ------------------------- REVIEWEDBY------------------------ ---------------------------------- -------------------------------------------=---------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------•--------------- - ---------------------------------------'--------------•----------------------------•--•------------------------------------ .....------------ --------------------------------•----------------•---------------- ----------------------�--- -----------------------------------------------------------••------------------------- -----------------------------•--- FINAL INSPDate--- Y�-- 1 r -- -------------------------------- 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 �� G.5 9 REVISED 6.59 31+1 3-'63 F.P.0 G.