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FOR OFFICE USE: f (,-.-f-------------------). 3 0 --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..Z,7 -------------------------------------------------------- (Complete in Duplicate) This Permit Expires_1Year From Date Issued Date Issued _ 1.. - 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 Ordina e ho. 54 363 JOBADDRESS AND LOCATION- -r------/---- ------------------------------------------------- ------------------------- ---•---------•----------------------------------------------- Owner's Name--- --- �`--- - ---- -------------------------------------------- -- ----- ---- Phone------------------------------------ Address------------ -------------------Address------------ --------------••- ---•-•------------------------------- ------ Contractor's Name ` �> `�1 ------------------ Phone----------------------------------- Installation will serve: Residence k�r Apartment House ❑ Commercial ❑ Trailer Court ❑ _Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms __---- Number of baths ______ Lot size --- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table .02ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑. Adobe tr—Hardpan ❑ Previous Application Made: (If yes,date-----------_........) No Dr---New Construction: Yes ❑ No +FHA/VA: Yes ❑ No ff~—_ TYPE OF INSTALLATION AND SPECIFICATIONS: z (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi nk: f Distance from nearest well_________________Distance from foundation--------------------Material________.__.___.__.._____..____________.___.____. No. of compartments---------------------- Size--------------------------------Liquid depth---- --------- ------ __Capacity Disp❑osalFel y Distance from nearest well.%1_A—-------Distance from foundation___ _--- -.__-.Distance to nearest lot line_-/?0-_I__ Number of lines________________________________Length of each line-047--f------------------ of trench---- Type of filter material_ _` pe�[�-_- Depth of filter materiaL_l1---t�---------Total length------- --------___________�__� Seepage Pit: Distance-to nearest well_-/r�U-�--------Distance from found ation_ •'p_-----Disfance to nearest lot line______ Number of pits__..==!------ _Lining material_rA_v.4_7C.....Size. Diameter._.-__ __...__-------Depth----- _ ___________________ Cesspool: Distance from nearest wei------ _:_bistance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter---- `-------------------- ------).Depth-------------------------------------- ---:---------Liquid Capacity--- ------------------------gals. Priv Distance from dearest well-------------------------------------------------Distance from nearest building_____.__________________ W ❑ Distance to nearest lot line------------------- ------------- - -•--------------------- -------------- ------------------------------------------------------ W I Remodeling and/or repairing (describe):---------------- -----------------------------------•-•-------•----------------------•----------------------------------------------------------------- ------------•---------• -----------•-----------------------------•------------------------------------------------------------------------------- --------------------•-------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------------••--•-------------------------------------------------------------------------------- --- G --------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- ------------ 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)----------------------- -- -- ------- -- ------------------------------ -----------------------------------------------------------------(Owner and/or Contractor) By--------------------- ---- -- --------•----------------------------------------------------------------------(Tifle)---------- -------- -------- - --- - - -- - -- - - - --------------- (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- •- -- -------------- ------- --------------------------------- - -------------- DATE--- �` / G -------------------------- - REVIEWEDBY------------------------------------------ -------------------_------ ---------------------------------------------• DATE------------------------------------------------------------ BUILDING PERMIT ISSUED -------------------------------------------------------------------- DATE Alterations nd/or recommendations---- ---------- ------ ---------- ------ ------------------------•----------•---••------------- - ---'�®-------------- ---------------------------------------------- -------•- -- S@-e-c A Q.. , CICi'----/-? /- FINAL INSPECTION BY -- t - Date------ . l _ ------------------------------------- 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nozeiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 6-59 3M 3-'63 F.P.CB.