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FOR.OFFICE USE: w APPLICATION FOR SANITATION PERMIT Permit No. ...... .7: ------- -- ----------------------------------------- ------------------------------------- ----------- (Complete in Duplicate) / ----------------------------------------- ------------.__ This Permit Expires l Year From Date Issued Date Issued ----- .0 Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordin nce No. 549. . ,-� z �. 1 ------------------------------------------------------ JOB ADDRESS AND LOCATION._ i.l �r7fi�,clC - A-.!_1..----�'` ' OwnersName------ •------ -- --------------------------------------- ------------------------Phone------------------------------------ Address----------- ---••--------------------------Address----------- ------ -Q-•- -- --------------------------------- --- .---•----•-••-----------•-... Contractor's Name----------------------- ----------------------`--------------- ------------------------------------------...--------------- Phone................................... Installation will serve: Residence,a Apartment House ❑ Commercial E] Trailer Court C] Motel ❑ Other ❑ ., Number of living units: ---/ Number of bedrooms Number of baths ---/-- Lot size ...... .-_______________________ Water Supply: Public system,`, 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 JR' Hardpan ❑ Previous Application Made: (If yes,date----------- -------- No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ 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-_/b-&—tistance from foundation i® _____...Materi� ecYzr ca ------------- No. of compartments----------�--------Size----Y_X_..y- - -Liquid depth-------�--------------capacity--- , .5 ._-- Disposal Field: Distance from nearest well---A&EDistance from foundation_____.-al -D'stance to nearest lot line-__.��...... Number of lines--------- __: -----Length of each line____---.--. 'Vt -idth of trench....____ ---------------- -------- ______________ , Type of filter material____ __oelpthof filter material_______:/.2f_.-----_.-Total length___-_ _____r Seepage Pit: Distance to nearest well____=� tance from foundation...f Di to o nearest lot line_____ a''. Number of pits---------I_________Lining material---K,�_ _ .~-_.Size: Diameter__ __ _. ____Depth__ ._.-.________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------- -=•---.Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------ ------Distance from nearest building-....--__-._________-_____.-.---_-___----. ❑ Distance to nearest lot line.-- --------------------------------------------•-------------------------------------- --------------------------- -------------------------- modeling and/or repairing,( scribe):-- . _ �'`----- Le -- - `�"'"Y"" d�"�f.-Ea"�-��/►=F�w.-•- ---- --- --f +'�---C'�--------- - --A -- ---I�•Vz:-- .......... //--- --'-----.._.. I hereby certify that I have prepared this applicati and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of he San Joaquin Local Health District. Si necl /� ---------e------------ ------------ ---------------------(Owner and/or Contractor) �. ( 9 )- --- - --------- `�-;1' J /C. BY: -----------------------------------•------------------------------------------------------------------------------------------•-(Title)---------------------------------------- ------ (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 APPLICATIONACCEPTED. BY---- --------------------- -----------------------------------------------•---------------- DATE------- �? f ------•------------------- REVIEWEDBY-------------------------------------------- --------------------------------------------.. DATE--------------------•------- ------•-------•-•------------ BUI LDI NG PERMIT ISSUED---------------- ----------------------------------------------------------------------------------- DATE-------------------------------------- ---------------------- Alter do s and/or re�comm ndation - ------------------------- - - - ------ ------ ------------------------ - ----- - ?-'L �� _' -- ----2='`- 6c7 cQ -------------------- ----- ----------------- ------------------------- .� ►3 Y { 9--f----------------- FINAL INSPECTION BY:.--r .. --- _ ��-�[--�-�- �—$ — (<- `L------------------------------------------- SAN ----- 1 - ----- - - - ------------------------- Date----�----------...-- • -- ---- ---------•------------------ r�- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street, 205 West 91h Street Stockton,California .Lodi,California Manteca,California Tracy,California E5.9 REVISED 8-59 F.P.CC,2M 6-66