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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. •. __ .. ........ ------------------------------- (Complete in Duplicate) Z - - --- 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 Ordinance No. 549. 1 JOB ADDRESS ANDOCATION-- ----- - ---------------------------------------------------------------------------------- fr I Owner's Name lr)' '�, = I - J----------------------------- ------ Phone------------------------------- '. ---------------------------------------------- ----- Contractor's Name--- ---•-- } ------------------------ _ Phone----•--•-----------------i Installation will serve: Residence A artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:_ ______ Number of bedrooms .-Number g __ Number.of baths -��--- Lot size 46 x___-" ---•------------------ ----- Water Supply: Public system Community system ❑ Private El Depth to Water Table ._b-pft. i 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 ❑ iNew Construction: Yes ❑ ,.No ❑ FHA/VA: Yes ❑ No Er_� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ~� , Septic TTank: Distance from nearest well--- ------ from foundation) ---___________Motorial-_--______�ti B ---__.___.. � LlP � =------Size---- �'� �-------Liquid depth =--------------- Capacity No. of compartments ____ ---. .--- Dispos Ield: Distance from nearest well---.- -,.-----Distance from foundation._'! k-----------Distance to nearest lot line.--.--- .--/... Number of fines___ ��.�i__�__---------------Length of each line.--_737. _- 1'4_______._.Width of trench,,_Bit.t IType of filter material__.N�L ----.-----Depth of filter material_1_'r_`�_____.____Total length-_- 4 :-._________-__________ t Seepag it: Distance to nearest,well____'"`W=_-._-.-_-:D.istanc m #oandation__;ZO ----- _:D t 14 to nearest lot line--:47----- Number of its_____ _ __ _____Lining materiar- d_G ___.Size: Diameter77------__--------------Depth------ 2)..___ # P ------------- Cesspool: Distance from nearest well-________________Distance from foundation-----.-------------.Lining � maternal-____---------.---------- ❑ Size: Diameter--------=--------------------- ------------------------------------------------Li Liquid Capacity-------------------------f---gals. . Y Privy: Distance`,from nearest well--- __--___----'___ __________________________Distance from nearest building---------.---------------------:______--- ❑ ° Distance.to nearest'lot line________________________ s • � � i. � I Remodeling and/or repairing (describe):--------------------------------------------------------------------'--------------- ------•--------------------------------------- `---------- i J '� M _' 4 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 rodulations of the San Joaquin Local Health District. (Signed) ----- ________________________ Owner and/or Contractor By:---------------------- -------- --------- -- •-- -------------- -----------------"---------------------------------------------(Title)---------------------- i-------------------- ---- ----------- (Plot plan, showing size lot a ion'of system i relation to wells, buildings. etc.. can,be.placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY I ----------- --------------- DATE -'� -�---------- --------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE---------------------..------------------------I---------- —'BUILDING PERMIT ISSUED------- `" ------------------------------------------------ DATE ' Alter;�tions and/or recon en ati s:__:___ -- / ��4 --" ---" __= r } x _ ------------.7_--_._._-.__i____._---_ __________________________________________________________________________________________________________________________________________________________________________________________________________________________ 7777 FFNAL INSPECTION BY:----- ... _: f_ ---------------"--" ---------- Date--.--1_. "_ ---. # SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISrO B-59 3M 3-'63 F.P.CO. - 1