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FOR OFFICE USE: ---------------- --------- ---------------------- ---- ------------------------- - ------------------------- APPLICATION FOR SANITATION PERMIT Permit No. •...................... -------------------- -- ------ ------ - ------------- (Complete in Duplicate) Date Issued / T ----_.-I 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. JOB ADDRESS AND LOCATION-------------�O.A o------- ! Yl s �--- ---------------- -------------------------------------------------- Owner's Name-----------------------r66,4_1�----- OAF- ,Pis---------- -------------- --------------- i------- ------- Phone------------------------------------ la,A---�...... ------12a/-----..............---------------- --- Contractor's Name--- 1 y L - l �------------------------------------------------------------•-------- Phone---Y�_A,l. w( Installation will serve: Residence ED--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __j____ Number of bedrooms __-�__ Number of baths -------- Lot size _______ ---/_PC1_________--____ Water Supply: Public system ❑ Community system ❑ Private E411!Y"epth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date--------__,........} No New Construction: Yes E oo ❑ 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__ Q____Distance from foundation----/_®.........Material----- e ..C... --------------------- [, No. of compartments----------- Size __Liquid depth__________________________Capacity----f��'O__ Disposal Field: Distance from nearest well....:67�2---Distance from foundation------ .0........Distance to nearest lot line-----,j-_— Number of iines_____________ _________________Length of each line_____________________ !7 Width of trench--------------_ Type of filter material_ o- .sr&Depth of filter material___-I�/i t..Total length-------3-4�__j__________________ Seepage'Pit: Distance to nearest well----------------------Distance from foundation______________`-_-.Distance to nearest lot line__._______-___.._ ❑ Number of pits______________________Lining material----------.------------Size: Diameter__._-__-___._.-___Depth ______________- G Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_____-__________-________________-_. Size: Diameter-------------- -- Depth------------------------- __-_-_______Liquid Capacity __________gals. m Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______________________________.___...___. ❑ Distance to nearest lot line- - ------------------------------------------------------------•---•----------------- ------------------------------------------------------ Remodeling and/or repairing (describe):------- --------------------------- ------------•---•----•---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------•------------------•---•}---•-----------------•------------------------- -------- -------------------- -------------------•--•-----------------------------------•------------------------------------------------------------------------I--------------------------------------------------------------------------------------- ------------------------------------------------•--------------------------------- --------------------------------------------------------------•--------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County P ordinances, Itate law , and rules and re cations of the San Joaquin local Health District. 9- (Signed__ ----- - _ _ _ _`a ��-` - �- ------(Owner and/or Contractor) y: `��lfc C - ---- -----------------------------------`-----------------------------------(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 BY-- ------------------------------- DATE------ �' --------------- REVIEWEDBY------------------------------------ ------------------------------------------------ -------------------------------------- DATE-----------•------------------ BUILDING PERMIT ISSUED-----------------------------------------------------"---;------------------------------------------- DATE----------------------------------------------------------- Alterations and/or recommendations:._.----------------------_----------------- ------------- ------------•----------------------------•-•---•--------------•--•--- --------------------------- - s - 1 -------------___--------_______--------------------------------------------------------------------------------_-------------------------------------------------------------------------------------------------------- ---------------------------------------- • r. FINAL INSPECTION BY:-/..;�_4_,;v- _ f ----- -------------------- Date f1_ .---------------_-------------------------------- 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 E5 9 REVISED B-59 3M 3-'63 F.P.ED.