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--------------------------------------------_--_--___.._. APPLICATION FOR SANITATION PERMIT' Permit No. (Complete in Duplicate) pp This Permit Expires ] Year From Date Issued A - Date Issued Thilication is her made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s application is made.in:compliance,with County Ordinance No. 549. r- C/W Q1,4 J B ADDRESS AND LOCATION. --•--- -•- r Owner's Name------/ ____ -------------- Address--------------------A" ---------------------------- --=------------------- ---------------- Phone --/3--�-----• _c--'`�-----•---------_ ' Contractor's Name___- :- -- --•- --- e -- Phone---------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: (_"- Number of bedrooms ---3___ Number of baths 1'E-_- Lot size y ❑ Water Supply: Publics stem ❑ Community system.❑ Private ® Depth to Water Table �� ft. Character of soil to a depth of 3 feet: Sand El Gravel [-] Sandy Loam � %Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date_..__._.__..,____".._) No© "New Construction: Yes f +] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: �► (No septic tank or cesspool permitted if public sewer:is available within 200 feet.)} Y x Septic Tank: Distance from nearest well_"rl_a__.___Distance from foundation_./b • . ____--___-Materialt No. of compartments__ ------------- Size_ _s_- f r:_-.Liquid depth ----'%--------'Ca pacity_V17-_Ul?-. Disposal Field: Distance from nearest well''47" � Distance from foundation.__/.&__--__. � -__.Distance to nearest lot line--_S----_----- Number of lines----- -__ ,Length of each line___________-__3---��_-.Width°of french._-_"r�_ �� 1r- -Depth'of,.fil E ma erial_ --------Total length-_ b_'�-- 1 Type of filter materia ' $ !6� Seepage Pit: Distance topnearest wet Distance from foundation----_---------------Distance to nearest lot line----.-_.__.___-- ❑ - Number of its----------------------Lining material-'___-_--------- -.Size:-Diameter----------- Deptht ------------ ------ { ' # Cesspool: Distance from nearest well-----------------Distance from foundation-- ---------------Lining material--___-._._____.______- -.__._ ❑ Size: Diameter.-------------------- --- : ---- De�nth_f_ -- t --------Liquid Capacity--- ------------- - --gals. ✓l Priv f / ,, Y Distance €ram nearest well :_- - _ Distance.,from nearest building_______________________ ❑ Distance to nearest lot ------------------- Remodeling and/or repairing fdescribe):�--------------------- ° -----•------------------------ -------------------•---- ------- r r ------------------- -------1---------------- --------•--------------------------------------•---------- ---------•--- ---------------------__----------------------------------------------------------------------------------- - 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 regulations of the San Joaquin Local Health District. _ (Signed) -- ---- --- ---- --- - --- s - = _(Owner and/or Contractor BY ---------------------------------------- ----------- �, '_ --_—_. {Tit e) ) (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_ --------------- REVIEWED ---_- -___ - ----- ---- ----------- ------------------------------------------- DATE--��' �-Gra REVIEWED BY ---------------------------------- -------- -- -------------------------------------------------------------- DATE---•---- BUILDING PERMIT ISSUED-------------- - ------------------------ --------------------------------------------------- ---------. DATE-- ------------------- - terations and/or recommendations: ----- - _ FINAL INSPECTION BY:. . ' `� ---------- Date ._' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha>elton Ave. 300 Weal Oak Street ` t 124 Sycamore Street 205 West 9Th Street Stockton,California y�. q • Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 3m 3.'63 F•.P.CO. ' -- 3