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FOR OFFI SE: _ APPLICATION FOR SANITATION PERMIT Permit No.----------------- ------------------------------------ -- 3 r -------- -------- ---- ------------- (Complete in Duplicate) ------------- date Issued --------•--�-1-_..1 +' — __._.-' 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 No. 549. 13or (,so 3� �% JOBADDRESS AND LOCATION------- - -=------'�'-----------------------------•--'�`---•-•-•----- -- -----------------------------------•---•-------------•-••:-------------• ------ - le—Dt+ Owner's Name.----- --------j •-------------------------------••------•----- ------------•-------•-"-•-----------------• Phone--.--------_------------ ------- Address.- --------------------------------------------------------- .L _ - - ---------------- ---- Contras#or's Name �.... ------•--------------- Phone...------------------•---•--_.... Installation will serve: Residence [D'•'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ------ Number of bedrooms a.1 - Number of baths _3--_ Lot size __��-�-�______________________________� Water Supply: Public system ❑ Community system ❑ Private a Depth to Water Table,''--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe©J Hardpan ❑ I Previous Application Made: (If yes,date--- -------------) No [y' New Construction: Yes s� No ❑ FHA/VA: Yes [INo ®� TYPE OF'INSTALLATION AND SPECIFICATIONS: (No septic tank,or cesspool permitted if.public sewer is available within 200 feet.) f Septi `Tank: Distance from nearest well-----------------Distance from foundation.--_---_-.--_._-._.Material------------------ :_..________...____..____._._. G � No.' of compartments---- ------------------Size----•---------------- ..........Liquid depth---------------- ---------Capacity----------_------ ---- Disposal Field: Distance from nearest well_,,!-------_-_Distance from foundation-./k- ------------Distance to nearest lot,, O---_•-.- Number of lines---------..-1------•-- ----------Length of each line------/��- ..------•--.Width of trench----- ;------------- �-------- Type of filter material.`�_G�-----___-Depth of filter material /_ - ..........Total length-.--- a _ _________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------..__.Distance to nearest lot line------------------ Number ----- _.--_---Number of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth•--.----------------_------------ Cesspool: ------------•--_- ------Cesspool: Distance from nearest well ................Distance from foundation--------------._._-.Lining material-----------------------------------.-. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy:; Distance from nearest well----------------------------------------------- from nearest building------------------------------.---- ---. ❑ Distance to nearest lot line--------------------------- ----------------------------------- ---------•------------------------•----------------------------- i � 1 Remodeling and/or repairing (clescribe):-------------- ----- ---------: ----------------------------------------------------------------------------------- --------- i. --- -- - -"----- ---------------•----------------------•----------.....--------•----------•------------ .. .. -------------- ----- -------- I her 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, e •� f 1� i (Signed) ------------------------------------------------------------------------(Owner and/or Contractor) Title---------------------------------------- -------- ------------- BY� ---------- ----- ----------'---Dok_------ ------------------------------ { ) I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i .. .. FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY...... ------- -------------------------------- ------------------ ---- DATE ) �'' ` �`' t ---------------- 1 REVIEWED BY.-.--- ------------------------ ---- DATE -- BUILDING PERMIT ISSUED------------------------- -- — ----------------- ------------------ DATE.. ---------------------- Alterations-and/or recommendations----------------------------- - -------------- } -•------------- -------------------------------------------------------------- ------ __-------- ---------------------------------- --------------------------_.... ' ' i F1NAL' INSPECTION' BY:_..._-�. ------------------------------ SAN -------------•----------- Dete ` 4' ----------------------------- FI - f•Q� SAN JOAQUIN LOCAL HEALTH DISTRICT t 130 South American Street 300 Wast Oak Street 124 Sycamore Street 205 West 91h Street ` Stockton,California Lodi,California Manteca,California Tracyr California f. '� E8.9 REVISED 8-59 F%P.CC•2M 6.60