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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------ -------------- (Complete in Duplicate) //z Date Issued .._. _0-11'a-C7 -_ --_.____._._______________________________________ I This Permit Expires 1 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 Count rdinance No. S49. JOB ADDRESS AND LOCAT N.. l� �'`��G`-'2� •� --------�'•-) Owner's Name------- �rx' ---- - -------- --------------------1. ------------------------------------------------ Phone:,rx -------------------- Address.......... :r • �.... • --- .. -- t4----- ------•--- ----------------- --------------------..........---------- --------------------- Contractor's Name__. . .- —__ -------- - --- - -------- ----- -- -----------------t--- - ------ ---- --.---•---• Phone _ _ ____3_22�v Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/_`Number of bedrooms ____/_ Number of baths __J___ Lot size PCZ - `-______________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table,__4L?_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoaA Clay Loam ❑ Clay ❑ Adobe❑ 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 --Distance from foundation/ �6 Mat real Cj,• • - -- - ------------- 7 No. of compartments------9.----------------Size._.,�_1<'_l/-_-.--_...Liquid depth_��.--------------Capacity-----�W d----•-- Disposal Field: Distance from nearest well- _Distance from foundations -....Distance to nearest lot line_"b;;;--'_____. C] Number of lines--------4 Length of each line-------,-r__ �-'____._.Width of trench__' ____________________--- (� Type of filter material__ Depth of filter material____ __ r� Yp - - p -------Total length----- ---------=----------•--....--------• V` Seepage Pit: Distance to nearest well--- ______Distance from ndation__4..____....Distance to nearest lot ------- Number of pits______ ___________Linin material Size: Cesspool: Distance from nearest well-----------------Distance from foundation--------------------.Lining material-------------------------------------- ElSize: Diameter--------------------------------------Depth----------------------•----------------------------Liquid Capacity-------_----•-------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-.-_-.-----------------------�--_._. ClDistance to nearest lot line--------------------------------------------------- -•--------------------------------------------------------------------- - -f-' -� Remodeling and/or repairing ------------••----••------------------------------------------------------------------ -----o ------------------------------------------------------------------------------- -- .._-------------------------- ------------------------------------------------- ----------------•----------------------------------------------------------....-------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------•-------•-------------•--------------••-------•------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StVlaws, les and regulatios of t e San Joaquin Local Health District. (Signed]_ ---- - -- --- - -------=� {Owner and/or Contractorl BY�-------- ��--------------------------------------------------------- ------------------------------- Title [ ) - (Plot plan, showi�g size of lot, location of system in relation to wells, buildings, etc., can be placed on revers side). /FOR,PE! ENT USE ONLY r APPLICATION ACCEPTED 8Y--------- -------- -- ------ DATE �� 4��. REVIEWEDBY----------------------------------- ---------------------------------------- DATE------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-----------------------------------------------------------------------------------------------------------------------------••----••------------------------ ------------------------------ --------------------------------•-----------•------.------------------------------------------ ----------------------------------------------------------.------------------------------------- ------------------------------------------------------•-- --------------------------------------------------------------------------------.....--.._._..------------------•----------••--------------------------------------- 1 * _ FINAL INSPECTION BY: - --- ---- -- ----- Date i; (P�-----------------------------_--. 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 E6.9 REVISED 8-59 F.P.00.2M 6.60