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IOFFICE USE: (d = L APPLICATION FOR SANITATION PERMIT Permit No. ... _. .•._.- (Complete in Duplicate) �s y -------------- ---- -_._ - --- --_ .___-.__.____.__.._._ f This Permit Expires 1 Year From-Date Issued Date Issued 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._/-_-Z 4.-----1-- ------------------------------ -----------------------------------------------•------------------------------------------- Owner's Name-- J + `�--------•---------- -------- Phone------------------------------------ z� 2s- � Address------------- .......... - ---••-•----...---•-----•----------- - - - - - - --�- Contractor's Name..-_l * ..---- 9r---- --- - Phone----------------------------------- Installation will serve: Residence t❑—Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living Number of bedrooms _3__ Number of baths/______ Lot size - Q- I ---_________________________________-- I , Water Supply: Public system. PR---Cmmunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: , Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑'�Clay ❑ Adobeardpan ❑ Previous Application Made: (If yes,date............:.......) No E�' New Construction: Yes EP—No ❑ FHA/VA: Yes ❑ No ln_� v TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool perinitted if public sewer is available within 200 feet.) } Septic Tank: Distance from nearest well_ -____-Distance from foundation_40__f_-_____.Material________________--___ ____.-.-. [ No. of compartments_____ `t`�.._--------------Size____ __ sS--x_ ._._Liquid depa h------ .............Capacity...Y'a_p Disposal Field: Distance from„nearest well_ --------Distance from foundation/-a_---____---------Distance to nearest lot line.__sS----.... . Number of lines____{__._^------------------Length of each line-_-�jS__ V7Width of trench__ _ __,`_---_-___--..___ Type of filter..material7fat— '________Depth of filter material-_/.�r�_________..Total length---_--1470_-____________________ a :w, !' ,/ Seepage Pit: Distance to nearest well-------"----------Distance from foundation--_�d.----------Distance to nearest lot line-----------------___.__ _j [l� Number of pits_________________Lining material--- -__AC-t_.__.Size: Diameter____ .T__--,-------Deptn-_. .Y__--________-__ pQ Cesspool: Distance from nearest wel!---------------__Distance from foundation--------------------Lining material---------------------_---------------- ❑ Size: Diameter------•-------------------------------Depth----------------------------- --------.-------------Liquid Capacity----------------------------gals Privy: Distance from nearest well ____---------_----------------------------------Distance from nearest building------------------------------------------ n ❑ Distance to nearest lot;line------------------- --------------------------------------------------- --------------------------------------------------------------------- 1 'T Remodeling and/or repairing (describe):-------------- ---------------------------------------------....----------------------------------------•----------------.._-..------------ - I --------------------------------------------------------------=-------------------------------- ------------------------------------------------•------------------------------------•-•------------------------- 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 Joa in Local Health District. t (Signed) -- -- ----- ----------------------------- ------- ------ --------------------------- ------(Owner and/or Contractorl By------- - ----- ,_e------- ------ ------- --------------------------- -------------------------(Title)---------------------- -------- - ---- (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). " ; 'j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--=-C =r te---- -- --- ----------------------------------------------------- DATE---- -------- REVIEWEDBY--------------------------------- ---`------------ -------- -- ---------------- -------------------------------------- DATE--------- ----------------------------------------------- BUILDING PERMIT ISSUED = ------------- ------- ---------- --------------- D/9E --- --- -- - ----- - --- Alterations and/or recommendations------ -------- -------- -l /f- -- -- ----_:------ � -- --------------------------------------------- ------- -------------------------------------------------- --------------------------------- r --- - --------------------------------------------------------------------------------------------- - ----------------------------------------•------------------------------------------•-•---------------------------------------- . I ----------------------------------------------------------------------------- ----------------------------------------- ------------------------------------------------------ --------------------------------------- FINAL INSPECTION By `"-='�------------------------------------- Date---------10........ 2 = ---------------- ------------------------- R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVMCC] B-59 3M 3-'63 G.P.Ca.