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FOR OFFICE USE: . - - 3 v } APPLICATION FOR SANITATION PERMI Permit No. .��. .Q__�_ -----------------------------------------------------------w � � {Complete in Duplicate} Date Issued ------------------ ---------------------.----------_._._ t This Permit Expires 1 Year From Date Issued r 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 Ordi nce Ifo. 549. 1 JOB ADDRESS AND OCATION--------- -- -� --------------- -------------------------------------------- ------------------- Owner's Name---- ----- t .. Y -�'+-X-- --------------------------------------- -------------------- Phone----------------------- ----------- •3'�------ ...-------------------------------------------- Address Contractor's Name ..... ` ------------------------------------------------• ------------•--•- Phone--------.._..-------••------------- A. Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ R I Number of living units: __ _ Number of bedrooms :_ __ Number of baths --.rLot size __l__►�. _.__ _ �------------------- Water Supply: Public system [4—iommunity system ❑ Private ❑ Depth to Water Table fs_ ft. Character of soil to a depth of 3 feet: : Sand ❑ Gravel ❑ Sand ..Loam ❑ Clay Loam ❑ Clay El Adobe[�iardpan C]Previous ApplicationMade:. 11f yes,date-----------....__ .I No New Construction: Yes FHA/VA:,Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k Distance from nearest well-----------Distance from foundation/a_______________Material' /(p- --- -.-----.-------- No. of compartments-- _______Size____ fir __ Liquid depth---- ____ __ _________Ca acit e '� Disposa -eid: Distance from nearest well_-----"-------Distance .from.foundation__- r--------Distance to nearest lot line___ Number of ------------_---Length of-each line__Ifj___---------------.Width of trent __. ._jf--,-__-------------- _._ w `' ------Total length--- LT en th---- Type 6f filter material___�4S.--rC•__Depth.of-°filter matenal__ ._f�'._.____ g i Pit: Distance to nearest well_. Distance °, foundation__.19------------Distance to nearest IQf line L Number of pits______------------Lining material:-------CL_a.0 ___Size: Diameter__,33__..._ p •C Cesspool: Distance from nearest well-----------------Distance from foundation-__ _--__-__-._--__.Lining material____..___-__-_.-________--_--.__.--._. - ❑ Size: Diameter-------------------------------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy: . Distance from nearest well---- --------------------------------------------Distance from nearest building---_--------------------------------- Distance uilding______________________.________-----_Distance to nearest lot line--------- ----------------------------------------------------------------------------------------------------------------------------------- s Remodeling and/or repairing (describe}---------------------------------------------------------.-------=------- ----------------------------:----------------•----------•---------------• J ------------------•---------------------------------------------- ----------•----------------------------•---•-------- '------------------------------ -------------------------------------------------- . -------- to - - - -----------------------------------------------------•------------------------------ ----- ------------------------------•----------------•----------------------------------------•----------------------- I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations f t San Joaquin Local Health District. Y �. --------- ----- -- --r----'-------- -- (Signed) -------------------------- --- ---------------------------- ---------{Owner and/or Contractor] i . -- ---=------------------------------ By: {Title) (Plot plan, showing size of lot, location of sys em in relaf n to wells, buildings, etc., can be placed on:reverse side}. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----- -•-------------------- - ----------------------- ---------------------------------- DATE------- a ---------------------- REVIEWEDBY-------------------------------------------------- --- .......... ----------------------------------------------------------- DATE----- ------•----------------------------------------------- BUILDING PERMIT ISSUED--_--------------------------- ----- DATE-----------------=---------�-- - Alterations and/or recommendations: l -. ._� ---•- ------- -- --------------------------•- -------------------------------.------------ -------------- ---- --- --- - �� /�o- �'-< -------------------------------- ---------------------------- . . - ---------------------------------- I -----••-•----------------------------------------------------- -------------------------------- ------------------------------- -------------------------- ----- ------------------ --------------- -------------------------- ------------------------------------FINAL INSPECTION BY-- ------------ -- -- --- --- -- Date'----- - == y 7 ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED 8-59 3M 3-•63 F.?.CD.