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FOR OFFICE USE: rY -------------------------------- - -------------------------- ------ ----------------------- APPLICATION FOR SANITATION �ERMIT Permit No. ..1_�/1'�___ l___.________________ __ {Complete in Duplicate) /h 1;i!?' ------------------------ f -.__-�_------_--------------__ This Permit Expires 1 Year From Date Issued Date issued ______ S Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This a licatiol- is made in compliance with County Ordinance No. 549. �j�(� ! 2,.Q-37 AND LOCATION.. �- �.f�'c JOB ADDRESS .. -- Owner's Name-- > �/?rry� --- ----- -- Phone Address------------ ....... .........------7 ,l Contractor's Name.--► A........--------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will.iserve: Residence PP Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Numbedof living units: _1____ Number.of bedrooms._ -_ Number of baths _.2-- Lot size P_-'__�p'_ ________________________________ Water Supply:' Public system ❑ Community system ❑ Private, } Depth to Water Tables~ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ( Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------1 No 53 New Construction: Yes, ] No ❑ FHA/VA: Yes ❑ No ❑ _ TYPE OF INSTALLATION AND SPECIFICATIONS: �J (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_s _-_-____Distancq,fro foundation___l_V_�______.Materia4-_-__ .__-t""___________________.._._______. IN No. of compartments----�-_._-_._ I ----------Size-�-tet --�---- --•---Liquid depth---�--- ---- ---------Capauty/.zLf�'--�----, Zt Disposal Field:�� Distance from nearest well J-0 .......Distance from foundationZo ________.Distance to nearest lot lines!___'_________ .I , Number of lines__.-_________ ._________.._Length of each line____�_ Q__'_.______.Width of french--- r___________________ it Type of filter materi��-� Depth of filter material____f.�__'_________._Total Iength__,A-_9_1i9-- I Seepage Pit: f Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.________-__--- s ❑ I� Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------- Cesspool: -------------------- ----Cesspool• Distance from nearest well_________________Distance from foundation----------------._ lining material ...____.._._____._.__.___________.__ ❑ Size: Diameter----------------------------- --------De th------ ------- ------------------------ i p ------------Liquid Capacity----- --- -- -- ---------gals. Privy: i`t Distance from nearest well------------------------------------------------_Distance from nearest building_____-_-____-_--.---__________.___..____- ❑ II Distance to nearest lot line-----------------_ -----------------------------------------•---------------------------------------------------------- - --------- Remodeling and/or repairing (describe):-- ---------------------------------- ----------------------------•--------------------------------- ---------•-•-•------------••------------------------ ;,-•--------------•------------------- -----------------• ---------------------...------------------------------------------------------------------------------------------------------------------------------------- ------ -----------------=-------------------------------------------------------------------- •-•---------••-•-------------------------------------------------------------------------------------------------------- ----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, +ate laws, and ru s �andregulatiions of the San oaquin Local Health District. (Signed)__I_____; -- ------- -- ---- -------- --- ------ ------ -----------------------------------------------------------------------(Owner and/or Contractor) Piot plan, sho -- -- -------------___________e------------- - ------------------------------------------------------------(Title)--------------------------- [ p win size of lot, location of sys+em in relation to wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY o APPLICATION ACCEPTED BY ----------------------------•--------------------- DATE---- --------------------- REVIEWEDBY------------------------------------------------------------------- --------------------------------------------------------.. DATE------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------- ------ ------- -----------j----------------------------------------------------------------- •---------- ---------•--- - ----------- -----------------------I--------------------------------------------------------------- ----------- ---------------------------------------------------------- --------- ---------------------------------------- ------------------------'I---------•------------------1•-•-•----•-------------------------------------------•---------------------------•-------------------------•---------------------------------------------------- 1i -----------------•='------------------------------•------------------------------------- ----- i� ---------------- ------------ ------------------ ---- i� FINAL INSPECTION BY:-- _ --µ ;_._..4oI --------------- Date__6___ - ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ma:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3•'63 r.P.ra. �;�•' II .