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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 5 - ----------------------------- - ---- --- - -- --------- (Complete in Duplicate) Date Issued ___/�/3 -• ________________________________--------_______-....-__ 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 Ordinance No. 549, JOB ADDRESS AND LOCATION. l`4�-�/ _ #Z-� � aL MSs- C3GI�� p Owner's Name-------------------------- �� rte/ �t�/L3�S_ _7Q.W.d -------- .. . �' ---.-. Phone---�---- Address - ------- i --•-------•------------------------ ------- --------------------- Contractor s Name -------------------------------- -- Phone---------------------------- '--1 Installation will serve: Residence Imo, Apartment House ❑ Commercial ❑ Trailer Court (] Motel ❑ Other ❑ Number of living units: ____/_ Number of bedrooms _`�_ Number of baths _ _. -- Lot size --------S6-x._/.s-0______________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _ 'ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,K Hardpan ❑ Previous Application Made: (If yes,date____ --------I No ❑ New Construction: Yes W No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) c Tan Distance from nearest well____ __________Distance from foundation-------!�__._---Material_________._.____._____________.____-_____._____- No. of compartments- ---- -------=--------Size--------------------------------Liquid depth_--------------- ---------Capacity------------------- Disposai Field: Distance from neaJrest welL___.*_S��Distance from foundation---- ± __'------Distance to nearest lot line__________ Number of lir1�4lC___-_.�'___.-._ Length of each line------------ -�-------Width of french---.------a_V_Of _ � —O-�C�l Type of filter material____ _Depth of filter materiaL__• �` _-_Total length----------------------s r___ Seepage Pit: Distance to nearest well____-_____�___ i•sstance from o cation------°��7.._.___. istance to nearest lot Numf�er of its_-____.__i- _Linin material ize: 9iemetCr _ ____Depth110 � �-- P_G p g Cesspool: Distance from nearest well_________________Distance,fr_om foundation---------------------Lining-material____-.-___________-__________________ ❑ Size. Diameter- - ---- - - --------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. r. Privy: Distance from nearest well___________________________________ ____________Distance from nearest buiiding------------------------------------------ 4— IJDistance to nearest lot line--------------------- - ------------------•--------------------------------------------------------------------------- Remodeling nd/or eSair'ng (describe):--------------- ---- ---- ---------------------------------------------------------------------------------------------------------- ----------•- - -- ---- I hereby certify tFiat I have prepared this application and that.the work will be done in accordance with San Joaquin County ordinances, State laws,land rules and regulations of the San Joaquin Local Health District. (Signe - - --- �`----- ------------------------- ------- ------------------------------------------------(Owner and/or Contractor) I By:---------------------------------- (Title) r (Piot 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---------------------V 0.4-—--------------------------------------------------------- DATE------- _______0 `----------------------------------------------- -_______d__-_______y__________________-._ REVIEWEDBY-------------------------------------------- --------------- ----•--------------- ------------------------------------------ DATE-------------------•-- ------------------------------------ BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------------------------- DATE.............------------------ Alterations and/or recommendations:------------------- ----------------------------•----------•--------------•---------------------------------•----------------------•-•------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------- ----------- = - ------ ---- ---------------- ---------------------------- ---------------- - ------------- ---- ------ -_--"_f +___-.3 � ___-.__ _ __._-.____-_-._ __-__a- cam_ _.__,vxt._ elrt _-.�___.__��1f_ .--------------- ------------------ FINAL INSPECTION BY:_._._...L-�... -_.� r Date------ c -- ----------------------------.---- �'�---------------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoxelton 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.CC.