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FOR OFFICE USE: -------------------- Permit No. .-.................... APPLICATION FOR SANITATION PERMIT „ .......... -- ------------ ------- ---- - ----------------- --.- (Complete in Duplicate) Date Issued -------------- -- ------------------------------------.--_ This Permit Expires 1 Year from 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 549 , • -- ! JOB ADDRESS AND LOCATION ---------- - ------- / Owner's Name------------k-a_ ........... / -------------•------------------ ----------------------------------- --------- I Phone__•��_�_19� --- 4 t:� -6-1s s Address-------------- _� C� `J --------------------------------------------------------------------------------I——------------------------- Contractor's /•• - -- ---... Contractor's Name__.--- � S ..l �� ---•-•---._ Phone..L7 7--- Installation will serve: Residence 25 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units..---/-- Number of bedrooms _3_ Number of baths I--- Lot size ---- � `-_---------I-------------- Water Supply: Public system 95 Community system ❑ Private ❑ Depth to Water Table -------- ft. p Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ i Previous Application Made: (If yes,dpte__--_- ---------1 No ( J New Construction: Yes ❑ No ® FHA/VA: Yes ❑ No jj TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-------- ------Distance from foundation----------------- Material_--------____-----_-----_-_-_-_-----------____. ❑fiXjSr1NG' No. of compartments-__ --------------------Size-----------------------• ---Liquid depth- ---------------------- Capacity----------------- ---- s / Disposal Field: Distance from nearest well_/t/OWd_Distance from foundatioryfkW- -_`PJ_.Distance to nearest lot I1�-- -------- Width of trench----r ---------------------- �k)eI571m6 Number of lines._-d�A/ .__-_ '--------Length of each line----- _-_--_ , . t►OD Type of filter materiaL__S-�,� ___Depth of filter mate ------------ length------- .+ -_----___________ _____ ^' Seepage Pit: Distance to nearest well--AleAIA----_--Distance fr foundation__ -�P_-_........Distan� to nearest lot line----�-________ Y Number of its__ --�� Size: .Diameter-----;U_'7-----Depth_ ,tel'--.-------_ Fdk/Si/�� P• � .�- ----Lining material_----Y--""� p , •4pP Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material [� material------------_-__-_-_-------___-_ ------------------------------------- ._-gals.Diameter------ --------=---------- ----------Depth--------=----------------------------- -------------Liquid Capacity Privy: . Distance from nearest we11--__--_--_--__--------------------_-_--____ --Distance from nearest building__,_.-,---------__-__-_-------_-- -----. ❑ Distance to nearest lotline -- -r------------------------------------------------------ -------------- ------------------------------------------------------- IT { W 1 int z.. Remodeling and/or repairing (describe)---�� --------0� --�Q--.�'X.IST.��---- �T�//I----------------------- ---------------•------------• ••----------••-------------••------------------------------•-------------------- 1----------------------- ----------------------------- ---------------------------------------------------------- --------------------------------------------------------------------------------------------------- -•--------•-•------------------------------------------------------------------------------------------------------------ ------------------- ------------------------------------------------------------------------------------- ----------------------------•----------------------------------------------------------- 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)-------- y �✓ �. = ----------------------------- (�Ow r and/or Contractor) Br• ._.. "----------------------- (rtle)-- (Plot plan, showing size of to#, iota#' n of system iri relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY A ---------------- ---------------------------------------- DATE----fd ~x 7'= -- --------------- REVIEWEDBY----------------------------------------------------------- - ------------------ - • ----------- --- BUILDINGPERMIT ISSUED-------------------------------------------------------------------_---------------------------------- DA-TE------------------------------------------------------------ Alterations and/or recommendations:-_/A-37-- �G c� '�' Z'1`------------------•-----••----------------------------------•------------- FINAL INSPECTION BY:- ---- ---------------- --- --------------------- Date..../� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California A ES 9 REVISED 0.59 31A 3-'63 F.P.CC.