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FOR OFFICE USE: --- --------------- ------ ---------------------- --- --- 3 L --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----- ----------- - ------------------ :.--- --------------- -- - - - (Complete in Duplicate) ____________________________________ --------------------- This Permit Expires 1 Year From bate 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. 7y A)1 QzS—(gyp -3a 17s-5-#, x1. ,Q,,s ✓Ac&s /�-- JOB ADDRESS AND LOCATION. ' t-,� e�_ " ..f Owner's Name t<< _ �Aen------- ----------- ----------- Phone...-----------------••-------------- Address.......................... ' Contractor's Name-,_ - � g /t*. Vie__ .._. --------------"f--�, --- -- ��^�_-- Pherre. "'� '------ Installation will sere: Residence C@ Apartment House 0 Commercial 0 Trailer Court 0 Motel Ej Other Number of living units: ___I____ Number of bedrooms .'�_ Number of baths ___-L Lot size ---- !C/1.(! ________________________________ Water Supply: Public system ❑ Community system ❑ Private L� Depth to Water Table �--fl ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay ❑ Adobe❑ Hardpan p Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ j TYPE OF INSTALLATION AND SPECIFICATIONS: __(No septic tank or cesspool permitted if public sewer is available within 200 feet.) w i Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material__---__-----'_----__.________________________ No. of compartments--------------------------Size--------------------------------Liquid depth----------- - _ -_Capacity _______ Disposal Field: Distance from nearest well.tS`�..-_____Distance from foundation-----AO/-------Distance to nearest lot line__0-�-------- Number of lines____ _______ ----------Length of each line-------Zq---------------Width of trench__- -_ !'------------------ Type of filter materialA __/_1-_U _Depth of filter material-___._-_g'C___.-Total length____7-_i-________________________-._ O Seepage Pit: Distance to nearest wel(---------- from foundation----------------___.Distance to nearest lot line----------.-_-._-El {� Number of pits------ --------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- G 1 Cesspool: Distance from nearest well_________________Distance from foundation_,.- ------------,-- Lining material---._____.________-___.____________- ❑ Size: Diameter--------------------------------------Depth---------------------I-------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------_____----------------____________I-------Distance from nearest building----_ -----------------______--_.-_--_-_. ❑ Distance to nearest lot line-.:----------------------------------= ------------------------------- ------------------------------------------------------------ Remodeling and/or repairing (describe):_____-._ ---►- --- -��^ -- ------------ •-lys� .s�rY1--------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- - ---------------------------------••-- ----•------------------------------------------------------------•---•----------------------•-- ----.---- ---------------------------------------------------•------------------------------------------------------------------------------•-------------------------------------------------------------------- V 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) _ 4 �r�r�l 2► ^"fir- ----------------------------(Owner and/or Contractor) By:---- ------- --•-- --- - , ------------------------------------------------------------'------------------------(Title)------------------------------------------------------ -------- 1 (Plot plan, showing ize o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_,,-,4— � ______-________ _ - DATE--f7- -- ----------------------------- REVIEWED ----------------------------- REVIEWED BY----------------------------------- --- --- ----- - --------- DATE- ------ BUILDINGPERMIT ISSUED-----•-------=--------------------------------------------------------------------- ------------------ Alterations ----------------Alterations and/or recommendations:-------------------------------------------------------------=-------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------I----------------------•---•------------------------------------ ------------- -------------------------------------------------------------------------------------------------- ---------------------------- ------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ------------------------•------------------------------------------------------------------------- -----•-------------------------------------------------------------- ------- FINAL INSPECTION BY:. � � - Date J� ` -- -- --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVISED 5-59 3M 3-163 F.P.CO.