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FOR OFFICE USE: __________________________________________________ APPLICATION FOR SANITATION PERMIT Permit No. ..:.._.{ _.. --------------------------------------------------------- (Complete in Duplicate) �� ... � --- _ _.-._--.- ------------------------------------------ This Permit Expires 1 Year From Date Issue 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. 3 930 N �� L .p,4 �(�'7 JOB ADDRESS AND LOCATION ` �''� ``"------------------------------------------------ Owner s Name .�. 1-s_x: -le----- t.� .F" Phone--------------------- ---------------- --- ------------------- _ - Address----------------e --------- --------------------2 - -- ------------------------------------------------------------- ----------------------------------------- Contractor's Name------- "'--•------------------- --------------•--------------------------------------------------•-------------------•--- Phone----------------------------------- Installation will serve: Residence E0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ...... Number of bedrooms .�--- Number of baths r.-. Lot size __ 'Y-------------------......................... Water Supply: Public system ❑ Community system ❑ 'Private [� Depth to Water Table ?47 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--------------------) No New Construction: Yes4 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_.,.:FQ-------Dista �e fro foundation----lA__.__-___ _Material._ _-.._---...-__--------------------------- ] No. of compartments----a------------------Size.-7-'- -+ -----Liquid depth._.._-L ---------------Capacity,../ _`u------- Disposal Field: Distance from nearest well-crb-------.-Distance from foundation._/b-._.---------Distance to nearest lot line.--..------. Number of lines------�r---------------------_ Length of each line---,lam-----------------Width of trench... - .�.........._._....__ Type of filter materia. f&�Depth of filter material.../9'?......----.Total length-.�------------------------------ W Seepage Pit: Distance to nearest wel____,f0--------Distance from f undation-/.d.._'____.....Distance to nearest lot line.. .......... q Number of its-' ---------------Linin material- .. . - 33-'-----.-De th---,%-�'------------------ �f p g -------.$ize: Diameter.-.-- � p Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material......-.-----.-.------------.------... ❑ Size: Diameter- ----------------- ------Depth------------------------------ ---------------------Liquid Capacity----------------------------gals.--� Privy: Distance from nearest well------------------------------T.- ..---..Distance from nearest building------------------------------------------_40 ❑ Distance to nearest lot line-- ------ --------------- -------------------- --------------------------------------------------------------------------------- --. Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------- ---------•-•---------------- ---•--------------•-----•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- -- - --- ---------------------- ------------------------------------------------•---•--•-------------------------------------------------------•----------------------------------------- - ----- - - 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)-----------1 -------- _4j.1t1_ - E--'1.?------- ------------------------------------------------------------------(Owner and/or Contractor) By:------------ -------------------------------------------------------------------------------------------------4--------------- -----(Title)------------------ ------ -_- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-. --------------------------------------------------------- DATE Z �l a REVIEWEDBY-------------------------------------------------------- -------- --- -------- ---------- -------------------------- DATE-------- --------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------- - ------ DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------------••------------- ----------------------------------------- ------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------- 1 FENAL INSPECTION BY: Date +°5�---SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.Cd. 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