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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._. .d _9 (Complete in Duplicated Date Issued ----------f----------- ------------------------------ -------- --_I--- __ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein de i ed , This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--'--. ______ _.___ -__ ___ _ ______________ ---- Owner's Name- lS---- ------------------------------------------------- ------ -------------------- ------ ------------ ---------- ------------- Phone---------------------------- Address----------------------------------�A/-46.-------------- G/d. _4---__--__ - � - --------------•-----•----.-.....-------------------------------- ----------- Contractor's Name---- - ------------- Phone------_---------------- Installation {i will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms __-_ Number of baths _1_____ Lot size ----1� ______________________ ___ Water Supply: Public system E] Community system [IPrivate p] Depth to Water Table _rf f _ t.�� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam IV Clay ❑ Adobe❑ Hardpan-[�j Previous Application Made: (If yes,date.__----------------j No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No sap#ic +a`nk o�cesspool permi#ed if public sewer.is available within 200 feet.) f Septic Tank: Distance from nearest well-----------------Distance from foundation_________________Material____-______--_--__..__--_-_-___---------..__---_. ❑ No. of compartments--------------------------Size-..-----------------------------Liquid depth----_ ------Capacity-------------��--- Disposal Field: Distance from nearest well._ d_._._._Distance from foundation---- ----------Distance to nearest lot line__•____._ i !� ri Number of lines--------.______ ength of each line_____. �-�___ _________Widfh of tranch_.��___-_.___..___._________ -- -------------- .�:�,._ w._. il. . Type of filter material __ � Depth of'filfer matErial_ :_____"-Total"length___- / _'__-:__--________-__.-___-- Distance to nearest wel A*SIIX- ---_ . Distance.,_from f9undation__.� Distance to nearest lot line_•�_f._. ❑ Number of pits------I-------------Lining material_-----Size: Diameter __?......___Depth--- &------------------- Cesspool: Distance Distance from nearest well-----------------Distance from foundation---.----------------Lining material-____._.____________________________ 0 ❑ Size: Diameter------------ -------------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line----------------------------------------------------------=- --------------------------------------------------------------------------- Ja Remodelingand/or repairing (describe)--------------- -- ----------------- ------------------------------------------------------------ -------------------------------------------------------- ---------------------------------------••--•----- -------------------•------------------------------------•--------------------------------------------------------------------------------------------=---------------------- --------------------=----------------------------------------------•--- --•---------------------------- •------------------------------------------------------------------------------------ ----------------------------- 1 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 rlies and regulations of the San Joaquin Local Health District. t71 (Signed)-•------�-----'-----��-------------- -- -- -------- ----------------------------------------------------- ------------------------------------------(Owner and/or Contractor --..,A. -- -----7r_ -Title_....... --=-------------•.•--•--------- ._._..,... --------- -~ w..- (Plot 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 DATE - ------------------- , REVIEWEDBY---------------------------- - -------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:--- -----------------------------------------------------------------------------------------------------------------••--------- ---------- --------------------------------------------------------------------------------------- ----------------------------------•---------------------------------------------------------•------------------------- --------------------- ------------ ----------•-•----------------------------------------------------- ---------------------- --------I- ----------- ------------------- --- -------- ----------------------------------•------------------------------- - - ------------ FINAL INSPECTION BY:_<TJE ------------------- Date 6. - ' --------------------------------- t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Kaaelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVISED 8-59 3M 3-163 F.P.CO. a'