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�. APPLICATION FOR SANITATION PERMIT Permit No. -17 ------------------------- ---�f------ (Complete in Duplicate) this Permit Expires I Year From Date Issued Date issued ------ Application is hereby made to the San Joaquin Local Health District for a permit to construe' sta t and inwok herein d cri This application is made in compliance with County Ordinance No. 549, es bed, JOB ADDRESS AND L CATION.............. ---------------------------- Owner's Name--------- --- --- Phone Address-------------------- ---------- -- --- Contractor's Name..................... Phone. Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: . .._._ Number of bedrooms �� ! g + --- Number of baths __..---. Lot size _/6�.X�-�J--'-- - Water Supply: Public system X Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay Adobe)] Hardpan ❑ date.... ---............1 NoX New Construction: Yes ElNoX FHA/VA: YesW No E]Previous Application Made: (If yes TYPE-OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________ ____cDistance from foundation--------------------Material_-...-_-....__-.....-...-__-....._.. L:1No. of compartments----------------- �Ll-Sue--- ----------------•-------Liquid depth-----------• -------Capacity------ ---------------- ` Disposal Field: Distance from nearest well�Ca_Distance from foundation•---�.`------Distance to nearest lot line__-sS./_.._- l Number of lines._.._....... .. ...............Len th of each line-....__ 3- fll� �} g �S-- Width of trench._. .. ,{ ------------ ( { Type of filter material-_' ___Depth of filter material------Z� `---Total length.._.._._--.- -._ i -- - . Seepage Pit _ Distance to nearest well."� e?__-_Distance from fo ndation..._ ?__'.._..Distance to nearest lot line.... --- "�4 Number of pits--..._.-�__...-._-.Lining material- - -. - E� Size: Diameter-- `Depth —� V! Cesspool: Distance from nearest well.................Distance from foundation..___I-.-_-._-.....Lin�aterial-..-.-_.----__-------_--- O El Size: Diameter------------- ------------------------Dept h-------------------------------------------- ------Liquid Capacity-. ---------------- - -------.gals. Privy: Distance from nearest well ...................... --------.----Distance from .nearest building ❑ Distance to nearest lot line___-....._------------- Remooddeelinq and/orirep lring (clescribe}:._.------- ii --- r .. ...--------------`----------------I------------------------ ------------------ ------------------------------------------------------••------ S .....................................,._._-_..___.._.------------------------------.---------------------------------------------------------------------------------------------------------------------------- _---- 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. �� w - y (Signed)---------------- � .1_ f `� - ---------------------------------------------------------- - (Ow' er and/or Contractor) BY:------------------- ------- rC -$stem in Z�-_----- - --- --------------(Title)------- y (Plot plan, showing size of lot, location of system r�etion to wells, buildings, etc., can be placed on reverse side). ti FOR DEPARTMENT USE ONLY i APPLICATION'ACCEPTED BY---- REVIEWED BY -__-- -------- ---------------------- -------- ~ DATE : _ ff: ------------- -------------------------------------------------- -� .. ----- DATEUILDING PERMIT ISSUED-------- ------------- ------ DATE----Alterations and/or r commendatons: '- K.- - � - ...... - - - -------- --� - ti -------- -------------- ! j � = " �- _ ---------------��_— .._c ..CC. � �� _ - ` ------ = ` �r FINAL INSPECTION BY:------ om`. - - y' - Date ------------ ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California >� C5 9 REVISED E3-59 3M 3-'63 F.P.CO. { t