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FOR OFFICE USE: ------------ 7 f < APPLICATION FOR SANITATION PERMIT Permit No.�_5� 4 ----------------------- -- -------------------------- ----------------------------- -------------------------- [Complete in Duplicate] Date issued --------------------------- ---- 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 County if No. 549. JOB ADDRESS AND CATIOf - -- -� Owner's Name---- -- --- -------- - - -------- �---------- --- ------- ------------------------------------------- ----- Phone--•-•------------_ --------------- Address --------------------------- .7.. .... ---------. •------------------------ = = Contractor's Name--- ---- ------- r� ------------------------------- Phone F x Installation will serve: Residencev�Aparfinent House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: _/__ Number of bedrooms Y9%__ Number of baths _/__ Lot size ! - , � ___________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table aeft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe @"Hardpan ❑ Previous Application Made: (If yes,date� No ❑ New Construction: Yes Kr*)�o ❑ - FHA/VA: Yes Z+--No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic TanklJ.�'� Distance from nearest well-----------------Distance from foundation--------------------Material ._- J�""- __- -____ G3 L9 �� No. of compartments--- - - ------------------Size---------------------------- ---Liquid depth-----------'-------- ----Capacity----- 1T' r Dis osal Fiel : Distance from nearest well----- �__._Distance from foundation__X�___-----Distance to nearest loo line_�P_.______ i__ __ Length of each line____ Number of lines -. - ------------ Width of trench_ Z Type of filter material-� - Depth of filter material---l�_______._Total length____ __ -------------------------------- tee age _____________________________beepage Pi . Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------------------ ,�f Number of pits--•-------------------Lining material------------------------Size: Diameter-----------------------Dept h--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------,_.--.---_______J�azl ❑ Size: Diameter---------------- ---------..Depth-------------- -------------------------------------Liquid Capacity--------------------- Privy: Distance from nearest well----------------------------------- ___________Distance from nearest building---_---______._______________ ❑ Distance to nearest lot line--------- - -------l---------------------------------------------- -------------------------------------------- ------------------------- ------ ---- Remodeling and/or repairing (de tribe :------ -- ----- � -- .__.-------d��/ .__---- � ------------ ------------------------------------------------ ----------------------------_-------- -------------------- - ---- , �_� s - . r------. -. 'mo i„ `'- - 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. Si ned)--------------------- /r ---- ---------------------------------------------- -----(Owner-endAr Contractor) By:---------------------------------------------- ------------------- -- --- ------ - - -----------------------------(Title)---IftkPlI�Z �- -------- -- ---------- --------- (Plot plan, showing size of lot, location of syste n ation to wells, buildings, etc., can be placed on reverse side). f /�� ----------------FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---rte` ----------- -------------------- DATE-------10�` =4------- - - - REVIEWEDBY-------------------------------------------------- ----------------------------------------------- ------ DATE-- -------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------ Alterationsand/or recommendations--------------- ------I---- ---------_--------------------------------------------------• --•-••----------------•------------------------------------------- --------------- ---------------------------- - ------------------------------------------------------------------------------------------------------------------•-------------------•---------------------------------- ------------------------------------------------------------------------------------------"------ --------------------------------------------------------•-•-----------------------------------------••------------------- ------------------------------------------------------------------------ --------------•-----------------------------------------•------------`• --------------------------------------------------------------------- ---- •-"--------------------------- -----------. _ Date_ L�' .r"Gt y FINAL INSPECTION BY:------ --- --- - - /--------------- -------- - ---------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 8-59 3M 3-'63 F.P.CD.