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FOR OFFICE USE- _ APPLICATION FOR SANITATION PERMIT Permit No. ....... )-5�- . (Complete in Duplicate) 7— ---------___________________________..__..____._____-- This Permit Expires 3 Year From Date Issued Date Issued ......�"�----------3 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. JOBADDRESS A LOCATION--•• j/ ��-------- --- ----- ------sL•G--..---------------------------------------------------------------------------- Owner's Name. ------ ---- -•----- -------------- - ---- --- -- - -- Phon - ' 2 _.]0 L - — _- � Address------ ----------------: ---- -------------------- - --- --------. .... - ---------------------------------------------------- --• --.....-------------- Contractor's Name-------------- ---- -- Phon .IR• f `a R Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Lj Other J❑ Number of living units:l�____ 1-0-k-40,Number of bedrooms -t_ Number of bathsLot size -------- - + ---------•--- Water Supply: Public system ❑ Community system ❑ Private Depth to`Water Table4/xft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe` Hardpan ❑ Previous Application Made: Ilf yes,date-_..:"__'..R------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic-tank or cesspool permitted if public sewer is available within 200 feet.) e r^ Se tic Tank: Distance from nearest well_�1�------Distance from fo�u}ndation-4-- _-------Materiel___ ____.------------------ Capacity ________________ No. of compartments----�----------------Size ~ <------ q p. VOL P y t Liquid de th__. P' _-Ca acit a __ Dis oral Field: Distance from nearest well_SQ. _ Distance from foundafion,3_,Q___�__.__.Distance to nearest lot line Q_______ i� 1 Number of lines.____-_______ Length of each line___. Q--0----..____._.Width of trench... ;--_ ___ Type of filter material Depth of filter materiaL___��____._..Total length_,____-__._._____ ___________________ i / f --__ _.".___.Distance to nearest lot line-.�3_Q_.. Seepage Pit: Distance to nearest well_�,O,Q_____ Distance f om f undation__�� xNumber of pits..../-------------Lining materia l_ t ' _.Size: Diameter.�_.3___F. Depth-----�--_______________ 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 to nearest lot line-------------------------------- - -----------•---- �3 -- --- &-- --------------------------�----- 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, St to laws, and rules and r ulations of the San Joaquin Local Health District. � 11 e (Signed]----- �1 ---- ------------- ` Owner and/or Contractor) B (Title) -- - -- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildin etc., can be placed on reverse side). , FOR DEPARTMENT USE NLY APPLICATION ACCEPTED BY_ /� . ---' y ----`�j�,---------- ----- -' ---------------------------------------------------- DATE - �',�7��=---------------------------- REVIEWEDBY--------------------------------------------- ---------------- --------------------------------------------------------------- DATE-------------------------------- ------------- BUILDINGPERMIT ISSUED------------------------------------------------------ ----------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:-------------------------- ••- ----------- ------------ -----------------------•----------------------•------------------------------------------------------- -------------------------------------------------------------------------------------------- ----------------------- -------------------------- - -----------------------------------------------------------------•-------- FINAL INSPECTION BY: Date SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma=elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California t Manteca, California Tracy,California r S E5 9 REV16ED 8-59 3M 3-'63 F.P.CO.