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_�Fo OF ICE USE: - ----------------- --------------------------------------- ---- ---------- A :OPPLICATION FOR SANITATION PERWT 4-- - Permit No. ----------- --------------------------------------------------- --- S/� (Complete in Duplicate) Date Issued --- -------------------------------- ------------------------- This Permit Expires I Year From Date Issued Applica.tioeis hereby made to the Son Joaquin Local Health District for a permip to construct and install the work herein,descried. This application is made in compliance with County Ordinaric No. 5494eK:5"1'1Z11191e�1111X- /fIlla- Z- -ount rdi n No 5 County 0 no c 49.,�e&4 Z2 Q JOB ADDRESS AND LOCATION .............. ------ ------------------------- -- -------------- -------eAl --- - -------- ------- ---------------------- ------------------------------------------------ ------------- . ... ... -------- - ---- --------: - Owner's ------------------, ---------------t----------- ---------------------- ------------ Phon - ------ ----- - -------- Address....-`fir--3r-..1L--•- Contractor's' Name------- . ............. :--------------------------- Phone-------------------------------- Installation will serve: Residence [3-7�parfmenf House ❑ Commercial Trailer Court E] Motel [] Other j Number of living units:.__!__: Number of bedrooms - ---- Number of baths t--- Lot size ---- Water Supply: Public system 1771 Commdnity system E] Private Yl---D--epth to Water Table QDff. Character of soil to a depth of 3 feet: SancY Gravel E] Sandy Loam E] Clay Loam ❑ Clay E] Adobe Hardpan Previous Application Made: (if yes,dote --------------- ---) No 9---Ne, Construction: Yes n—K, E] FHA/VA.. Yes E] No ®— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public ewer is available within 200 feet.) Septic T k: Distance from nea rest well-u:51------Distance from foundation----/6-1......Material__ ---- P No.' of comparfments��-----------------Size- ..........Liquid d-- ' -----------------Capacity---10V-------- 5--1 0 Dis Field: Distance from nearest wellv,�........Distance from foundation- ----1'---.Distance to nearest lot line---L------------- Number of lines__}. Length of each linvW-K--------_----.---_.Width,of trent h,�--517---'*---------------- Depth of filter material-/-X-------- -- Total Type of fi;ter mate 7,a*[-',---7-) length,___ ------------------------- Seepage Pit: Distance to nearest weif-------- -------_----Distancfe from foundation___________________Distance to nearest lot line---_--_--_-_._-_. i ❑ Number ine------------ Numberof pits----------------------Lining material----------------------.Size: Diameter---------------- -------- cesspool: Distance from nearest wel-------------Distance from foundation--------------------Lining material-__-.---___--------------'---_--_____. Size: Diameter---- ----------------------------Depth----------------------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest ]of line-------------------------- ------ ----------------------------------------------------------- --- f. Remodeling and/or repairing (clescrl6e):-------- /,-Z ----------------------------------------------------------- 7------------ --- ----- ...... -------•------------- = ---------------- -------- -------------- - --------------------------------------------------------------------- ------------------------------------ --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------*----------------------- ----------------- --------------------------------------------------------7-7-------------------------- --------------------------------------------------------------- I hereby certify that I have-prepared this appliction and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules andregula, s o he San Joaquin Local Health Districf.-i* ----- -------- - (Signed)---------------------------------------------------- ---------- ----------------------------------------------------------------------------(Owner anti/or Contractor) BY=-------------------- -- ------------ - ----- - --- ----- -- ----------------------------------------------------(Title)------------------------------------------ ----------------- % f 10 Z�� f y I (Plot plan, showing size,of 10 . ca of ystern in rel ion to wells,.buildings, etc., can be placed on reverse side). FOR DEPARTMENT YSE ONLY V.0 --APPLICATION ACCEPTED BY-_.-__-._ i ----------------------------------------------I.- 1 C DATE-.___.- �2-f�',7* REVIEWI�13-BY--------------------------------------------------------------------------------------------/--------------- ---------------- DATE-----7------------------I-----------7 ------------------------- BUILDING PERMIT ISSUED--------------------------------- ------------:'------------•--------------• ----------------- ------ DATE------------------------------------------------------------ Alterations and/or recommendations:------------------------------------- ---- ---------------------------------------------- ------------------------------------------ ---------------- ------------------------ ------------------------------------------------------------------- --------------------------------------------- -------- ------------------------------------------------------------------------ ---------------------------------------- f - -------- -- - ---------------------------------- ------------------------------------------ -------------I--------------------------------------------------- ---- ..- ----------------------------------- --------------------------------------- ------------- -- -- ----------- 3,t------ --- -----�-. ------------------------------------ ---- ------------------------------------- -------------------------------------------------------------------------- ---------------------------------------------- FINAL INSPECTION BY:---- --- *-------- - ---- __7--- ------------ Date--- -------------------------y.............. I------------- ------- - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 3M 3-'63 F.P.00.