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FOR OFFICE USE: ------------ ------------------------------ ---- -------- APPLICATION FOR SANITATION PERMIT Permit No. ___d,5�2e ------------ ----.--.-_.-.----------------- -- (Complete in Duplicate) .� . Date Issued ___-------T_--k 3 _--,.-------------------------------- -- ___ ........ This Permit Expires_1-Year From Date Issued - -- - O!3_lea 17 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: , _; -1 JOB ADDRESS AND LOCAT `1 __-t/V-------- -- ---Q�---`' --==---- ` --R"-° °" �' ---- -------- -------- --- ---- - - - ---------�- Phone------------------------------------- Address -.------------ Owner's Name-----(� ��--{------��.�•.._ ---•------- •----- Address---•--------. /5----- L 4------ -------------------- ---- ---------------------------------------- Contractor's --._-------- ----------------Contractor's Name �.. - " ----------- =--------------------- Phone----------------------------------- Installation will se �Re ence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units- ________ Number of bedrooms ___L Number of baths ---/--- Lot size ___ 1 ._ ,p, AL--------------------- 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 0 Hardpan ❑ Previous Application Made: (If yes,date---------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: l a (No septic tank'or cesspool permitted•if public sewer is available within 200 feet.) Septic •ank: Distance from nearest well",__5;0------Distance from foundation__-__ ------dg .__-____f__----------------- OQ No. of compartments--------------------`-ti- Size —fig Liquid dep#h---- p Y I s T `� s _Ca acit '� _ -J) . Disposa,,Field: Distance from nearest weii__. __-_.-._Distance from foundation----1.CP-__-------Distance to nearest lot line_________________ Number of lines----------- --�-- ----------------Length of each Ilne__________�_4----------.Width of trench------ -_r___------------------ Y `r r Type of filter matenaL✓SJ,_�_._______Depth..of filter matercal_._.__/�---------.Total length______�_t.�_____________________.___- Seepage Pit: Distance to nearest w`ell______________________Distance from foundation-__-_________:_____.Distance to nearest lot line__-_______.___._ O :' ; ❑ Number of pits.---------------------Lining material----------------------_Size: Diameter------------------ - --Depth___-___.-___________-.-___-• p Dia fi-om nearest well-----------------Distance from fouridation._f____.__.____._..Lining material------------------------------------. L Cess ool: ., , Distance meter-_. Depth-------------- Size: -------------------------- El _ Liquid Capacity - gals. Privy: Distance'from,nearest well----------------_------------------------------__Distance from nearest building___-____----_-_____________________-_-_. ❑ Distance'to,nearest lot line- -------- -------------------------- * _ Remodeling and/or repairing {describe)__________________________________________ ----------------- ----- �. . --•------------------------------------------------------------------------------------•---------------------- ----------------.------------------- ------• ------- -------------------------- -------------- -- -------•-- ---------- ------------ ------- . ----------------------..... ------------------------------------------•----------- - ` --'------------------------- ----------------------------------------------------- ---- ---------------------------------------------- I -------------- -I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules nd reg ulatio sof e San Joaquin Local Health District. (Signed)--------- - -- - ------ ------- -- ----- ------ -- ------------------------------- and/or Contractor) B ---=-(Title) M T _ r (Plot plan,.showing size of lot, location of system in relation to wells, bui tioings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED --------------------------------------------------- DATE--- ------------------------------ REVIEWEDBY-----------------------'--------------------------------------------- ----------- ------------------------------------------ DATE------ ------- BUILDINGPERMIT ISSUED--i------------------------------------------------------ ------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:------------ - ------------------------=-----+ -------------------------------------------------------------------------------------------------- --------------------- FINAL INSPECTION BY:.- - ------------- ....: Date-------------- -- ------------ ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r9 9 REVISED a-SO 3M 3-'63 F.R-120. - - - r�