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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, f. II ----------------- ------ -- --------- -- ----------- (Complete in Duplicate) Date Issued --- it - -- ---____---------------------------------- 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 ADDRESSAALoC TI -� - �'G'�llrre!�: Zar�.,CJ121 ��--- Owner s Name-- • •----- .'zrc --------------------------- ------------------------------ Phone------------------------- - Address {-- - ------------------------ h ' Cont1actor s Name--- ------- r �f ----------•----------------------- Phone----••-------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I____ Number of bedrooms __Number baths __ - Lot size ___ ___________-_-__.___ ____ . ��.._._- . t ,� F Water Supply: Public system ❑ Community system ❑ Private Depth�to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam C] Clay,Loam p Clay Adobe❑ Hardpan E] Previous Application Made: (If yes,date____________________) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I TYPE' OF INSTALLATION AND SPECIFICATIONS: Septi (No septic tank or cesspool permitted if public sewer is available.within 200 feet.) ank: Distance from nearest well/_____ "'._.__Di tent �from�founda�ion______ Q___._.Material___ •ll.-t�________________________ i 6k 0 No. of compartments-----"l---------------3if4 jW> Jf --Liquid depth----- capacity-Y V, [?�S/ Dispo 1 � s field: Distance from nearest well__-�i_`_-_Distance from foundation .®_._z____.Distance #o nearest lot line_.____S____________ ' Number of lines----------l_---------- Length of each line------- _ �— ----Width of french: _-`________________ Type of filter material------: _._____Depth of filter,material------/-rf_'_______-_Total length____:_�pp_________________________ s i See pa e Pit: Distance to nearest well-----I_G__Gs______Distance fr m oundation--------____--Distances o nearest 1 t line_.S"_____.._ � Number of pits____..__pG------Lining material_____=•----Size: Diameter___.___3__..___Depth----- . _________..______ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______.__________________-___-_. nl dSize: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Y1 Distance from nearest well______________________________________-_______Distance from nearest building g----------------------------------------- -� Distance to nearest lot line ---------------------- -------------------------------------•-------------------------------------------------------------------------- ort m I e ng ------ ------------------------ 1. ------------------------ -----------------------------------------------------------------------------------------------------_----------••---------------------------- 4 •-------- ------------------•--------------------------------------------------------------------------------------------------.--.--------------.-----------------------------.._ ------------------------------------------------------------------------------------------------------ -•-------------------------------------------------------------------------------------------------------------.. I hereby certif t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinjance$, State I ws, d rules an ulations of the San Joaquin Local Health District. (Signed)---------- ------------------- - -- ------------- - --------------- -------------------------------------------------,-' and/or Contractor) By: ' [ '� �' (Title) ---------- --------- ------- --- (Plot plan, showing size of lot, location o system in ration to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------------------------------------------------- DATE----- --------------------- -- REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------- DATE------------------------- BUILC}ING PERMIT ISSUED------------------ ---------------------------------------------------------------------------------- DATE----------------------------- - -------- ----------------- Alterations and/or recommendations:------- --------------------------------- - -------......•-----------•-----------------------•-------------------------••-------------------------------- r 1. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ il -----------------------------------------------------••-----------------------------------------------------------------------------------------•-----------•-----•-------------------------------•----•-------------------- J ------1. - ----------------------------- ----------------------------------------------------•----------------------------------------------------..._.--------------------- -------------- -------------------- //- qq 01� FINAL INSPECTION BY:----- ------------------ Date. --- ------f__------------------------------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Sfreef 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVlSED B-59 3M 3-'63 F.P.Cd.