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FOR OFFICE USE: �<.• // / �l ___________________________/GtAPPLICATION FOR SANITATION PERMIT Permit No. - /_.._... 'j_!Y�---------------- ---------- — (Complete in Duplicate) �� 1 /3 - r' ---- -- - ----.--- 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 applicafion-is made-incompliance with County Ordinance No. 549, JOB ADDRESS AND LOCATE N__.i`�.�t ___i - -•- --------- - ------------------ I =, = Owners Name___ __ - `-_•_ -- -_- I l -------------- ---- -------- Phone--------- -------------------------- I` Address. ------------------- •.:. ., - ------------------------------ - ------------------------------------- 'k Contractor's Name------- ------------ +: ----- ---= --- _ Phone Installation will serve: tReudence [�partment`House ❑�Commercial '❑ ,Vail � filer Court El Motel E] Other [jNumber of living units: _ _ Number:of bedrooms„_-- Number o}f,baths !:_--- Lot sizeJ/_�<. _------------------------ , Water` Supply: Public system ❑ Community.-system ❑ Private Depth to Wafer Table Character of soil to a depth of 3 feet: ' Sand E] Gravel E] Sand y,Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8�rdpan El � j Previous Application -------......I Noj2r"New Construction: Yes Uj--Mo ❑ FHA/VA: Yes 94—No ❑ t 'i, I` TYPE OF INSTALLATkON`AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance fro' Distance ael ��-----Distan e from_f ndation___ `` ' p' j .� f Mat`rial -------------------- --- c No. of compartments_ � ------------------- .Liquid depth___------------------Capacity-Via.--- Disposal Field: Qistance,from nearesV°well---YP-a--Distance from foundation._Z --..-.Distance to nearest lot line-4'r__'�".___ Number -of lines-----�---- Length of each line___ f__-:_____---.Wid#h of trench--A---- Type of,filter materi'al_�6�Depth of filter material-- e _Totalr iength___ ✓� _y_____._._- J Seepag Pit: Disfance!to nearest well_.._` p-__+Distance fro fo ndation-__`�_�-_---M lace to nearest lot line_`._- -.--_ r Number sof pits-_..�r ------------Lining matarial__ -:Size: Diameter, _._.__...._- °O i Cesspool: Distancefrom nearest well:_----_--__-__ Distance from foundation--------------------Lining material-_-.---------------------------------------- t" IJSize: Diameter_---t'- t--------- :--------.-- Depth------------------------------------------ Liquid Capacity----------------------------gals . Privy:' Distance�from;nearest well-7. ------_--_--___ } ___-. -_ Distance from nearest building______ ____________ Distance to nearest lot'line------------------------ ------------ ---------------------- Remodeling and/or repairing (descrilae):---- ,( -,-- - -• .- -----• , I • r rte +'- ---------------- --- ----------•--------- -------------------------------- - --------------------------------- - --- I hereby certify that I have;orepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andfrules and regulations of the San Joaquin Local Health District. s Si ned ( 9 )-----------------a!`� - - -- -�-- ------=---/ - -------- -- -----:-------------. ._, ------------------------------ -- -• Contractors By:----------------`t��'"---------------- -- — (Title)------------ ---- s� f` (Piot plan, showing size of�lot, iota+ion of system in.rel n to wells„buildings, etc., can be placed on reverse side). a ` FOR DEPARTMENT USE ONLY APPLICATION:ACCEPTED BY----- --- ------------------- ----------------------- -------------------- REVIEWEDBY----------- ----- -------------------------- --------------------------------------------------- ------ DATE-------- ----------= BUILDING PERMIT ISSUED --.__--------=-----=---------------------------------------------- ------ DATE--------------------- -------- ------ ----------------------- Alterations and/or recommendations:----- -------------- - -- --------=------------= -------------- ------------- -------------- ---------------------------- /� �,� ---- -- r"<-- - �rzf -------- ----- ! C--'- /2 —G —G3 ------ c�`_ ter. `::----------- - -- . FINAL INSPECTION BY:-.--_.._. �� _— ------- ----------------------------- Date--- -------------------9---�'-may--- - �---------...----------- - ------. , y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California y Lodi,California Manteca,California Tracy,California E5 9 REVISED 8-59 3M 3-•63 F.F.00. 2