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/��R�OlFFICE USE: -. ----------- ---------------- -f------_______________- APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------- ------ (Complete to Duplicate) 3 • Date Issued --------------------------------------------------------- This Permit Ex ires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and instali the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION. _�/ P ------------------. - - ---------------------------•_-------------- Owner's Name----6L. -- ------ - ----•------------------------------------------------------------------ Phone_1+0 _7 2-_`I-sem Address------------------------5� Contractor's Name---------Y ........ ._ ' -------•------------- Installation will serve: Residence Eff Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A----- Number of bedrooms _3--- Number of baths -_1---- Lot size ------&_Q -------------------------- Water ------------------------Water Supply: Public system >d Community system ❑ Private ❑ Depth to Water Table -�Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Ej Clay ❑ Adobe®` Hardpan ❑ Previous Application Made: [If yes,date--------------------] No New Construction: Yes ❑ No)< FHA/VA: Yes ❑ Noj�r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank, Distance Distance from nearest well-----------------Distance from foundation-__-__-_-_-__..__.Material-_-_______-_-_____ --------------------------- ❑ j;1 .. No. of compartments-- -----------------------Size--------------------------------Liquid depth----------- - ------------Capacity...-------------------- Disposal Fie Distance from nearest well_Distance from foundation_-_.10_`....-.Distance to nearest lot line__- `.-----` f 1 Number of lines-__--___------I-------- - ----length of each line----_-_--� _�----_---.Width of french----------At'-----------_.-OQ CCct�[ Type of filter material-S --- -_Depth of filter material--_ _` ----L� ,___-rTotal length------------------ --------------)j Seepage Pat •� Distance to nearest well_-_tA-&_ --Distance from foundation-----[.;-.........Distance to nearest lot line--- -------..x N .,fi .Number of pits.--------I------------Lining material-,S-.... )L.Size: Diameter-------- -'�---Depth........RU................. 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------------------------------------------ 0 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ----------------------------------- Owner and/or Contractor By:----------------`-s r - -------- - -------------------------------------(Title)------- (Plot plan,-showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------fir ' � ------------------------------ DATE------ �~l ------------- r I-- REVIEWED BY----------------------------------------------- ------------------------------------------ DATE-------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- -------------- DATE---------------a-------------------------.----------------- Alteratiors and/or recommendations:-------1' f=-, -'------ "` f--�- -=�X:!E s-= t— �- _--1-.--�-�' ---`------�� - �. f --------------------------------- ----------- ---------------------------------•------------------------•---------------------------------------------------------------•---------•------------.---------•--•--•----------------•-------------•----- ------------------- -----------------------------------------B--Y-------------------------------rANJOAIQUIN ----------------------------------------------------- -------------------------------------------------------�----J------------------------- --------------.- ------------------------------ FINAL INSPECTION ---------- -------- --------- ---------- Date-------------- ---- ---- ----- ----------- ------ ------------------------- LOCAL HEALTH DISTRICT 1601 E.Haz*lion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3•'63 F.P.CD.