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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .... _ - - ------------ -- r21� - ------------ C- - -----(oa (Complete in Duplicate) Date Issued . _^!.q .. 4This 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 withCountyOrdinance No. 549. JOB ADDRESS AND AT N•--.� -`-'-`i- ,-----��i��--------------------------------------------- ---------------------------------------------------------•-••---- Ad Owner's Name - -----. Phone �j /y -- ----- ---- dress------- <' ' ` fix-!_ l-- Q ---------------------•--------- Contractor's Name-------- Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,v i 01 Number of living units: __l--_ Number of bedrooms __2. Number of baths __l__ Lot size ------------------------------ Water Supply: Publi4'�system Community system El Private E] Depth to Water Table jcrA t Character of sail to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date.-_.---- .-_--) No Py"New Construction: Yes ❑ No PRO"'FHA/VA: Yes ❑ No g�— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet,) Septic. Fank: Distance from nearest well-----------------Distance from foundation--.----------------_Material--------------------------------------------_---. No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity----------------------- Disposal Fi Id: Distance from nearest well �'..._Distance from foundation.._ p ,p , Distance to nearest lot Number of lines---- _ Length of each line-_40-0-r----------------Width of trench---.I-/------------------------- Type of filter material_ Depth of filter material------ -----------Total length--------oe- ------------------------ Seepage Pit: Distance to nearest well----- ----_Distance fram fou dation__ Distance to nearest lot line--i�v--_..- a� Number of pits-------f_----------Lining material-_ _-Size: Diameter._. -------Depth_A '47!- -_--_--.---.--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.-_-_----__--------.------------.. ❑ Size: Diameter--------------------------------- ----Depth_------------------•---- ------------ --------------Liquid Capacity---------------------------gals. r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------_--_----_------__---------.-.----. ❑ Distance to nearest lot line------------------ ----------- --------------------••------•--------------------------------------------------------------------- Remodaiing and/or repairing (describe):---------------------- --`lw < ------------------------------------•------------•-----------•------------•--------------------------------------------- ------------------ ----------------------------------------------------------- ------------------------------=----------------------------------------------------------------------------•-----------------------•---------------------------------------------•----------------------------------------- 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 r les and regulatio s of the San Joaquin Local Health District. Signed(( 9 )------------------- -------- -------- ------- ---------------- ----- - --- ------------------------------------------VE = or Contractor) By:-------------------------------------------------------------------- ---- -----------(Title)---G'�-- " ---------- (Plot plan, showing size of lot, location of system ' elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ .. DATE ---- ------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE---------------------------------------- ------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------- ----------------------------- Alterations and/or recomm ndations:--------_-------------------------- -_ -L�--6 ` - c dry r ---- - - --- - -------- -- ----© ----- - --- - ----------- ------ --- --..........------- -"------- -----------------------------------------•--- ----• -------------•------------ --------------- -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY: ---------- ------ Date------------2 4 - ---------------20 —_ - ----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.flazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California. Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.CO.