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FOR OFFICE USE: ----------------------------------- - ------------------- ..................._______.__.___-_-------___.____-__. APPLICATION FOR SANITATION PERMIT Permit No. _1. ' 67- Complete In Duplicate) Date Issued - IVP4 ---- - ----------- ----- -- --- -" This Permit Expires 1 Year From Data 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. $2_r0,,,). LcwdS-.—d c ,,t. 7-a, JOB ADDRESS AND LOCATION- '--- -- ------ ---/ r r�---- __Y ----i-/- .Az- '�_..--------- 'L a " Owner's Name--__,Q --- -------- - -------------------------------------------- ---•------------------------ ------ Phone-------------------------------- vq Address f. f� °_`---- - t ContractorsName......... ---------"-------------------------•----------------------------------- --------------------------------------- Phone----..._ ---------------------- Installation will serve: Residence T Apartment House ❑ Commercial [] Trailer Court ❑ Motel [I Other ❑ •- r Number of living units: i------ Number of bedrooms __ _._ Number of baths t` Lot size _;L_3�j_aV _____________________________________ Water Supply: Public system ❑ Community system ❑ Private 0] Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam W Clay Loam ❑ Clay C] Adobe❑ Hardpan ❑ f Previous Application Made: (If yes,date---------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 _ Septic Tank: Distance from nearest well:_--------------Distance from foundation" ------—.-_°~ .Material____________________.__________-"----_._._____- ❑ No. of compartments------- -------------------Size----------------------------•---Liquid dei? h--------------------------Capacity..--------------------- Disposal Field: Distance from nearest well- Distance from foundation___-Yee _- __.Distance to nearest lot line_YU--_______ V [i Number of lines- Length of each.line_;z-_-— -'off`�°-^__.Width of trench-_ y_-____________________ ype of filter materi� Depth of filter material-19 ------------Total length--/ ------------------------------ ro Seepage Pit: Distance to nearest well_____ ______ _______Distance from foundation--------.----------Distance to nearest lot line_____-__--_______ ❑ Number of pits---------------- --.Lining material---------- -- --------- Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation.----_--------------Lining material_ _._____._______..___._____-..____ ❑ Size: Diameter____ _. ____.De th_-------_.____. ° _________Liquid Capacity gals. e_______________ Privy:_, Distance from nearest well-------------------------------------------------Distance from nearest building-----------___._________________._-__.. 3 ❑ Distance to nearest lot line----------------------------- --'!-------------------------------- ro Remodeling and/or repairing (describe):4X_•Ey'"-` .1- y------ --- t ----------------------------------------•----------------------------- -------------------------------------------------------------- -------------------------------------------------------. ----------------------------------------------•---------------'---------------------------------------------------------------------------- --------•------------------------------------------------------------------ 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 Sart Joaquin Local Health District. (Signed) / (Owner and/or Contractor) 9 By:----- =...�� = ) (Title)--------------------------------------------------- ---- ----------- ------------------ --- (Plot plan, owl g size of lot, location of system in relation to wells, buildings, etc., can be.placed on reverse side). F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -- ------------------------------ ------------------------- DATE__,3__A_l�S" ----------------------------- REVIEWEDBY------------------------------------------------------------------------------------ -------------------------------------- DATE----- BUILDINGPERMIT ISSUED------------------------------------------------------------•---------------------------------------- DATE----------------------------- Alterations and/or recommendations:----------------------------------------------- ---------------------------------------------------•----------------- -------•--------------------------------------------•--- ---------------------------- --------------------------------------------•--•----•-------------------•--•--------------------------------------•-•------------------- ---------- -------•------------------------------------•-•--------------- -- ----------- ----------------------------------------------------•------------------•----------•---------------------------------•--------------- ----------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------------------- ------ - --------------------------------------------------- -----------------------------------•--------- ----------- --------I--------------------------------------------------------- FINAL --:---------------------------------------------------- FINAL INSPECTION BY-._4e_ I Date ' ,�...... SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haselton 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.CC.