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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. - -.L ---.-•- --- ------ ----------- ------- ----- --- --- ------------ -- (Complete in Duplicate) ✓ D ---.-__ This Permit Expires 1 Year From Date Issued Date issued _______ j_� �Z/- Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS ANCATION------- -------------- --------------------------------•-------•----------------------•-------------f Owner's Name-------0161:�. ----------4_1--t.)*-•------••---------------------- -- ----------------•------------------------------ Phone--tv-0.--lor..-•-�— Address---------------------------------------- -- ---- - -t�---- �� 1 Contractor's Name---------------------- 0`--- --- -------------� a-- ----- --------- --- Phone...........----------------------- Installation,will serve:-Residence [1� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other N i Number of living units: __-I___ Number of bedrooms--. Number of baths _&-Lot size _ ?�r��_I_I_�______-_ Water Supply: Public system 0" Community system ❑ Private ❑ Depth to Water Table f$'rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay•[] Adobe[R-'-Hardpan ❑ Previous Application Made: (If yes,date____________________) No 2�1'_ New Construction: Yes 9?"'No ❑ FHA/VA: Yes R- 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______`"________Dista ror�sQur�daty n_J!L_____.___.Material___C' --------------------------------------- No. �I�(_C�._________._-___. Ev" No. of compartments____if_________ ___SizeS� + � Liquid de th____�(------ -_ .-.---Capacity-,/?;k 10 Disposal mid: Distance from nearest well_._.__--------Distance from foundation... 9----------Distance to nearest lot line_ ----------- Number of lines______.._-_.�.__--___________---Length of each line------ 0_'______________.Width,-of`trench_ _y_�'_______.__._________ Type of filter material.1l_;_yre�- -.Depth of filter material---/X'%_____.____Total length__ _f✓d__ _____________________ Seepage Pit: Distance to nearest well____________________Distance from foundation--------------------Distance to nearest lot line____--__-__--._._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---------------------- Depth-------.------------------------. Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material----------------------------........ . ❑ Size: Diameter------------------------ -rDepth-----;-----------------------------------=,. Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________-___-__-____-._______-__-_____-__. ❑ Disfa oce to nearest lot line-------------------------------------------------------------------------------------------------- ------------------------------------------- \ a';.-" . Remodeling and/or repairing (describe)------------------ .r ------- ' -----------------------------.__-_- - ------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------•--------------------------------- 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. (Signed) ____Owner and/or Contractor BY:-------------------------/ot.oloc, --- ------ -- ---� - ------------- Title /�J (Plot plan, showing siz on of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----C{----=-- ^ --------------------------------------------------------------- DATE-------- I L-------------------- REVIEWEDBY----------------------------------------------------------------------------------- ----------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------------------------•-------•------ Alterations and/or recommendations:-------------------------------------- ------------------------------------------------------•-----••-•--------•-------•---------- -------•-------------------- ---------------------------------------------------•--------------------------------------------------------------------------------------------------•------------------.....----------------------------------------- ...... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------•---------------------- FINAL INSPECTION BY:..... ----I-- ----------------------------• Date---- l M 7 - ------ _ ----•--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California ManteCar California Tracy,California EE-9 REVI9E0 9-59 F.P.CO,ZM 6-60