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FOR OFFICE USE- : ------------------ ---------- -- ----- --------- __,l $ . APPLICATION FOR SANITATION PERMITPermit No. G. ------------------------- -- ---------------------------- (Complete in Duplicate) _.._........ This Permit Expires 1 Year From Date Issued Date Issued _- :-- 5-- 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. POB ADDRESS A D LOCATION_/1-92 /01. .- '- �' ��-4= �' � '' =-� ' -----�'-'-`---- a--- A r Cr Owner's Nam � _ -• '- ` -- -------- ------------------ ---------- P .- _�. Address.-----•- - `�-'--- -- -��- -��-•--�=-t`--•----�-----------------'' --- - -- ---- --5` ---- ---------- -------------------- Contractor's Name..------ .L t, .. = ... _ j Phone.. _ - -------- Contractor's will serve: Residence [ Ap rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number-.of living units: .-[.---- Number of bedrooms _= . i�umber f baths _.. Lot size ..... f �.:� vi...._-..._ Vater Supply: Public system ❑ Community system ❑ ,Private Depth to Water Table ... ft. Character of soil to a depth of 3 feet: Sand ❑ Gravels❑ .Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ �y Previous Application Made: (If yes,date....................) 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-----------------Distance from foundation--------------------Material----------_._-__._......____----------------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth.------------- - ------Capacity------ ---------------- Dispos Field: -`Distance-from nearest well....x�'".--Distance :--.Distance-tofrom,foundation•-&4f.... nearest.lot.line__.._.�.:_......� � '` = _W idth'of trench. ---.------------------- / Number of lines_____________I'.... Length of each line_.`y. }_`.:. , I , . , Type of filter material_ e—.--.-----Depth of filter material- _ `.:...Total length...._.��`�`'..........................3 Distance to nearest well-----j VC....---Distance from foundation_--r. Distance.to nearest lot line.-.�.�...... -Z El Number of pits--.--- Lining material-e4V' -----"Size: Depth--..,;;:"* epth.... ...---...._-..._..--...: Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material-----..-----------..._...._------- ❑ Size. Diameter--------------------------------------Depth--------------------- ---------- --------- --------Liquid Capacity----------------------------gals. m Privy: Distance from nearest well------------------------------------------------Distance from nearest building-.-----..---_.__...------_.._-_..__---- ❑ Distance to nearest lot line--------- ------------------------------------------------------------ ---------------------=------------------------ ---------------- Remodeling and/or repairing (closcrib --•----------------------------------------•---..._ _ -.` ------------ -----------------------•-------------------------------------------------------- ---------------------------------------------- ------ _ -•-------------------------------------------`. �.�--•---------------- ---.-----------------------------.....---------------------------_------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- 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 nd regulations of th.e'San Joaquin Local Health District. (Signed) - - >/ ) and or Contractor By:-------•------- `r� --- - �--- . ----- �- (Title)------- ----------- --------"---'- ----- -------------- (Plot plan, showing size of lot, location of system in relation to w IIs, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- l, - DATE 3 REVIEWEDBY------------------------------------- --- ------------- --------- ------------------------------------------- DATE-----------•------------------------•--- ' BUILDINGG PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE--------- ---------------------------------------------- -- Alterationsand/or recommendations:---------------------------------------------- -------------------------------•--- ---------------••-•-•------------------ ------•---------------------------- -----------------------------------•-------------------------------- ------------ -----------------------------------------------------------.---------------------- ----------------------------------•-. ------------ ------------- ------------------------------ --- ------•-- ------------------ ------ ------------------------------------------------------------------------------------••----------------------------------------------- - ------------- ---•---------------------------------------•- ----------- ------------------- ----------------------------------------------------------------------- ------ FINALINSPECTION BY.-.- - '' .------A1• -. Date.- -------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD.