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FOR OFFICE USE: --------------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _...L._.lC...I.......... ------------------------------ - - --- ---------- ---- (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 described. This application is made in compliance with County Ordinance No. 549. GHQp JOB ADDRESS AND LOCATIONf-- / 1---`-- �-----•- Owner's Name----�-U_� .-�_----�-�1---- -- -='E'--'s---------------•--------------------- - ----- Phone----------------------------------------- •• •• • Address------------------ ----- ------- '}"'r'4-- ./y J ----------------------------- Contractor's Name, : ••-- ----- --------------------------••--------- - Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms ________ Number of baths -------- Lot size _ Bpi.' -. -l_________________-_______ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-:47Q--____Distance from foundation----/0---__---Material__��' {Z _____________ _______ No. of compartments------�-------------Size_YA_+F___?J---r_.---Liquid depth_.------ --------------CapacityjL_rp_------- Disposal Field: Distance from nearest weil..JV--___._Distance from foundation____- ___.__.___Distance to nearest lot line__......... Number of lines-------2r_______ _____________ Length of each line___.__ _ Width of trench---2-_ _ of filter materia�s%L. De th of filter material____._ __ __ Total length ------------------------- ------------------------ Type S p 9 �♦ Seepage Pit: Distance to nearest well____ )__-___Distance from f ndation___-/0-_-__.__Dista rce to nearest tot e__ ____________ J �] Number of pits___"'____________Lining material__/?e_vT ...Size: Diameter-----3_3-----------Depth_ -------------------------- Cesspool: ________________________Cesspool: Distance from nearest well-------------- from foundation---_----------------Lining material__._.______________._______._________. ❑ Size: Diameter--------------------------------------Depth-------------- --------------------------------------Liquid Capacity----------------------- -•gals. 6 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building._---_-__---_----_____-_-_____.__._..____.I 171Distanceto nearest lot line---------- ---------------------------------------------•---------------------------•- ------------------------------------------------------In Remodeling and/or repairing {describe]---------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------•---•---------------------------------------------------------------------------------------------------------------r ------------------------- --------------------------------------------------------------------•------------------------------------------•----------------------------•------------------------------------------------. -----------------------------•---------------------------------•--•---- ------------------._....... ----------- -•--------•-----------•---------------- -•--------------------------------------------------- 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 es and regulations of the San Joaquin Local Health District. (Signed)--------- .- _________________ ".-- Owner and/or Contractor BY: -----�------ -- --------------------------------------------------------------------------(Title)---------------- -- -------- - ----- - --- (Plot plan, showing size of lott, catio�fsy em in relation to wells;buildings,—ems: earl be placed on `reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED _ ___ DATE___ _' '_ _� .___.__________ ---------------- REVIEWEDBY----------------------------------------------------- "---- ------- ----------- ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------- -------------------—-------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:------------------- ---------------------------------------------------•--•------------------------•--------•- -•---------------------------------------------------------------------------------------------------------------------------------------------------•-----------._....-..----------------------------------------_---------- ----------------------------------------•----------- •I----------------------------- -- ----------•--------------------------------------------------------------------------------------------------------------------•--- -------------------• ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ----------------- ------------------------ ---------------- -- ----------------------- - ekl FINAL INSPECTION BY:_--�� ----------------- Date_-"- 7 fes_ ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ava. 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.