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FOR OFFICE USE: ---------------- --------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------=-------------- (Complete in Duplicate) ./ ____-----------_------------------- _______-_.._- 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 application is made in compliance with County Ordinance No. ,5,49.�p JOB ADDRESS AND LOCATI N _ 3sr;�_ d-tL,f.�[� G ' 'a��. CA____�_�.P � -4s _..... r ' Owner's Name 11_-T---- Owner's Phone......------- ------------------------------------------- ------------- ------------- Address -----------------•----------------••------ Contractor's Name----------- ,4 f. .r r• ��a��2�c-s..F----------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /__-- Number of bedrooms _Number of baths __j___ Lot size _______ _________--.--___..__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ------ ft�XAclobe - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [-] Clay Loam ❑ Clay ❑ 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--------------------Material---------------------------------------________. ❑ No. of compartments----------------- --------Size--------------------------------Liquid depth--------- - ----- --------Capacity----------------------- Dispo Field: Distance from nearest well.....eJ�9.P._Distance from foundation-----Zip---------Dis#ante to nearest lot Number of lines------------f--------------.------Length of each line__ 1?®___________ Width of trench__ .. ____________________ TType of filter material___�r_ �� YP �----------Depth of filter material---___.1/Y---------- length-------/6_d=�--------------------- Seepage Pit: Distance to nearest well----------------______Distance from foundation----.....-----------Distance to nearest lot line----------------- Ll Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- from foundation------------_------ Lining material__._____--__--.---_____-----_-___ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well ___-----_------------------------------------__Distance from nearest building-------------------------------- : ❑ Distance to nearest lot line------------------------------------------------ ----------------------------------------------------------------------- --------------------- Remodeling and/or repairing fdescribe)--------------------------------------------------------------------------------------------------------------------------------------------------------- - - ----------- ---------------- ------------------------------------------------------------ ------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and regulations of the San Joaquin Local Health District. (Signed) - _ -.d/or Contractor) $y:._..- ---------- - (Title) - _.. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ----------- --------------------------------------- DATE-- -------------------- REVIEWEDBY-------------------------------------------------------------------------------------------------------------------------- -- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterations and/or recommendations:------- ---- ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ------------------------ -------------------------------------------------------------•-------------------------------•---------------------------------- ------------------------ 1 -------------------•--------------------------------------•----------------------------------------------------------------------------------------------------------------------------- ------------------------------------ I ------------------------------ ------------------------•------'- ------ -------------------------------------------------------------------------------------------------------------- -------------------------- --- -----------------------------------------------------1-------------------------------------------------------------------------------------------- ------------------- ,FINAL. INSPECTION BY: -------------------- Date-------40�7_.' _4,--- ------------------------- SA'N JOAQUIN LOCAL,HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street y"' 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REV45ED 8-59 31A 3-'63 F.P.gp. '