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FOR OFFICE USE: - ----------------- .:3 f� APPLICATION FOR SANITATION PERMIT Permit o. .. .__ - ---------------------------------- ------------------ (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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. JOBADDRESS AND L CATION------------(73 --- -- --- -- - -------------------------------------------------------•---------------------- Owner's Name r..------ • .... -- ------------- = Pone. h Address ------------------- -------•-•--------------------------------------------------------------------•----/------------ Contractor's Name----------------- ------ Phone__ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] �Other El Number of living units: /------ Number of bedroom____ Number of baths __I.- Lot size ___-3- ---------------------•- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table --��---d ft. Character of soil to a depth of 3 feet: Sand E] Gravel [jSandy Loam F] Clay Loam ❑ Clay ❑ Aclobeg Hardpan ❑ Previous Application Made: (If yes,date/.f t- S;7_._} No ❑ New Construction: Yes ❑ No FNA/VA: Yes ❑ No E] E TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) w S Pa Distance from nearest well---------------__Distance from foundation_--_______________-Material____.____--_--_-______._____________--..----_-_. No. of compartments-------------------- -----Size-----.--------------------------Liquid depth.-------------- ---------Capacity---------------------- ? V f 1 : Distance from nearest well L��^-._Distance from foundation___D�_O_______.Distance to nearest lot' Number of lines-------/---- Length of each line---1 d--0--------------Width of french------�--C/_-------- ---------- or Type of filter material________!� -Depth of filter materEal-___�_�_____/ ---Total length Distance to nearest well r.�--Distance f om f ndation___,. _.. _ ___.Distan_Distance to nearest lot line- _.._-.. ll ' Ill Number of pits___..-------------Lining material, -_.Size: Diameter----3..3_--------- Depth-- -5_---------------- r esspool: Distance from nearest well-----------------Distance from foundation____----------------Lining material___--------______-_______..____--__. ❑ Size: Diameter-------------------------------------Depth_--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------- ------Distance from nearest building.---------------------------------------- 3 ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------•--------------------- e Remodelingand/or repairing (describe------ --- ----------------------- ----------------------------------------------------------------------------------------•------------•--•------------- Y ---------- ---------------------------------------------------------------------------------------------------------------•--------- ---------------------------I------------------------------------------------ ----- L -------------------------------- ------------------------------------------------------------------------------------------------------------------•----------------------------------------------- I hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc tate lawss d rulle nd regulations of the San Joaquin Local Health District. (Signed)_ ----- - --- ran r Contract ---------------- - ------ ----- - ---- ------ O ne and/or ori By:_ - `� --- [Title) (Plot plan, showing size of lot, location of system in relation to wells, I ings, a+c., can be placed on reverse Side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ �� rz�2,!,�n �_-------------------------- DATE ----------------- REVIEWEDBY-----------------------------------------_-------------- ----- ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED-----_------------------- --- ------ - t--------------- '=-------- DATE------------------------------------------------------------ Alterations and/or recommendations:___-�- ------ -- - - - ---- ------ ------ ------ - --- - ....... -- t ----------------------------------------•----•------------------------------ FINAL INSPECTION BY:...... ----------------------------- Date----- I------------------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hacelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED Ill 31% 3-'63 F.P.CD.