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FOR OFFICE USE: -------------------= -- ---------------------------- - APPLICATION FOR SANITATION PERMIT Permit No. _1_7.. __. - ^-�--- �-[Complete.in Duplicate) ------------- ___________________.._. 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 esc bed. Th is,a�pplicafi; is made in compliance with County Ordinance No. 549. 4 P JOB ADDRESS ANT -" - w ----- ! � w --:-`- ------- -- -------------fttts1-1—Y �W is' LO 4 _ -- Phone----------------"------------------ Owners Name--- 1 - -- -- -------------------•---------- = or Address -aCX_r -- ----- Contractor's Name----------- it ? ---- -- -------- ---- '.-------------- - ------ Phone---------------------------------- Installation will serve: -,Residence Apartment House ❑ 'Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_._ Number of bedrooms Number baths_,tr_ Lot.size___ _ _ _________________ _______ Water Supply: Public system El Community system ❑ Private [Depth to Water Table -------- f��Adoloe Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ ndy Loam ❑ Clay Loam /Clay ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------} No Naw Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: ( 0 septic tank,or cesspool permitted if public sewer is-available within 200 feet.) s Septic an k: Distance from nearest well_____5d__/D' tan e from fopndafipn___.f ._ __.Mat�al---. 11�L�____--------------------------- ---- _____________----____.-- No. of compartments_------ Size --_t� -- Liquid depth---'r�------------- p _-Capc &?--------- to nearest lot)ine___._____ _____F Dispos Field: Distance from nearest well--1-4-- from foundation._--... __ Number of iines.__. _-_ Length of. each line.____ Q_ `__._.Width of trench-m-7 _ of filter materia - ,_--Depth of-filter materia!_.__..f�---------Total length-_ C P--------------------- Type I Seepa e Pit: Distance to nearest well-_-,_-1_t�a-----Distance fr m ndafion____/_Q_.__..__.Disfance�to nearest lot line...5_--_-_- ; Number of pits_---_ -----------Lining material_. .. a .Size: Diameter...... p -------------- Cesspool: Distance from nearest well-----------------Distance from foundation----------------------Lining material--------------------------_----------- 1 t Size: Diameter-----------_--.______._ ------_De th----------------- _Liquid Capacity `__ als. _______________Distance from nearest building Privy: Distance from nearest well----- 9 f Distance to nearest lot line-------------------------------- Remodeling and/or repairing (describe)__________________________ --------•- --- --------- ---------------------- y --- ------------ - -------------------••--------=---------------- ------------------------------------------------------------------ «' "._-N1------------------------------- -----------------•---------- ---------------f----------------.------ ------------------------------------------------------------------------------------- E I hereby certify that I ve prepared this application and that the=work will be done in accordance with San Joaquin County -ordinances, State laws ru[ and regulations of the San Joaquin Local Health District. -- or Contractor (Signed)---------- --- --- ---'-- ----- ---,#----'---- -- -- - ----'---- ---_ F----'---- - --'- - - , ----------'-'- / 1 f - ---- -- -------=-------- --_ , --- ----- ------- ------ -----(Title)-------------------------------------------' (Plot plan, show of lot, location of system-in relation fo we ildings,.e c.,.can.be placed on reverse side). h 1t ` 1y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTI D BY_..- ----------------------------------------------- DATE ' ' r��'/---------' I REVIEWEDBY------------ -------------------- --------------- : ----------------`---------- ----------------------------------------•--• DATE------------------------------------ ------ BUILDING PERMIT ISSUED DATE--------------------------- - Alterationsand/or recommendations:--------- -------------------------- ------- -------------------------------------; --------------------------•-------------------------------------- i ! ! I + l' E y . i -- --------------------------------------------- ---------------------------" -------------- -------------•------------------- FINAL INSPECTION BY_: -- -. . .. -- .-1�-----'----------- Date--' ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-69 3M 3-'63 F.P.CR. I