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F R OFFICE USE: 1�a7 �1 APPLICATION FOR SANITATION PERMIT Permit No. � ......�.... (Complete in Duplicate) _ . !� - This Permit Expires 1l 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 -•--"- --- 4 r Owners Name , � ---- one-'it�fal-- /J, ------------- Address ---- Contractor's Name_-� .---_-_ -----------------...---- ------ Phone----••--_---_-------•----...__. Installation will serve:�Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-/_- Number of bedrooms.,- Number of baths 1'--- Lot size _17�--- --f —-------------------- Water Supply:, Public system E] Community system El Private to Water Table -------- ft. Character of soil to a depth of 3 feet: i Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date------- -----------) No ❑ New Construction r-Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: o septic ank or cesspool permitted if public sewer is available within 200 feet.) •'f k: Distance from nearest well-----------------Distance from foundation--------------------Material-_-_---_----..-._-_._._----_-_--_-______------. No, of compartments------------ -------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- le d: Distance from near s# well_�_Q -----Distance from foundation----__-_Q.-_..--Distance to nearest lot line_----,C_ Number of lines.___. __.. i Length of each line___ i` Width of trench_. _ ��----------------- g --- dA Type of filter material. _. Depth of filter materlal______� --_____._._Total len th_________________ s _____.___. Seepage Pit: Distance to nearest well--------------- Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits--------------------Lining material------------------------Size: Diameter------------------------Dept h-------------------------------.. t Cesspool: D}stance from nearest well---------------- from foundation......-.-------------Lining material------------------------------------- ❑ Size: Diameter----- ------------------------------!Depth-------------- ------------------_----------- ---.Liquid Capacity------------------------_-gals. Privy: Distance from nearest-well--------_____ --------------------------------Distance.from nearest building-----...-__---_-____--_---___-_-.._------ ❑ Distance to nearest lot line------------------------------------------------------------------------------- ------------------------------------------------ --------------0 , Remodeling and/or repairing (describe)---- --------------------------------- - ----------------------------------•-•----------•--------•------------------- ------------------------ C f--- �-/ ------------------------- - ------ ------------------•---------------------=- ---•-•-•-----'----------------- -- -- - ----------------------------------------------------------------------------------------------------------------------------------------- ------ ---------------------------------------------------------- y I hereby certify that I have prepared this application and that the work will be d ne in accordance with San Joaquin County ordinances, State la s, and rules and regulations of the San Joaquin cal Health District. ' - --- --------------- --------- (�r Contractor) -_-(Title)_ ---------------- (Plot plan, showing size of lot, location of system in relatt n to wells, buildin , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --- --------------------------- -- 5----------------------------------- DATE-------- ��' �a ----------- REVIEWEDBY---------------------------------------------------- -- --- -------------------------------------------------._.. DATE------- - ---- BUILDINGPERMIT ISSUED------------------------------------------- ------------------—-------------------------------------- DATE----------------------------------------------------------- Alterationsand/or recommendations:------ ----------:------------ -----------------------------------------------•---•------ -----------••--•----------•-•-----------•----------------=---------- --------- -----------------------------------------•---------------- ------------------------------------- ----------------------------------------------------------------------------------------------------------------- ----------L------------------------------------------------------------------------------------+-----------------------------•--------------------------------------------------------------------------•---•-------------- ------------------------------------------------------------ --------------------------------------------------------•-- ------------- -----•----- -------------------------------------------------------------------------- FINAL INSPECTION BY----------------- �-5-------H---------------� Date..------------- gel � X ----------- ------------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Haxelion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVISED 0-59 2M 3-'63 F.P.120. f