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FOR OFFICE USE: ---------- --------------- ------------------ - - ----------------------..____.---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..,1. ------(� ------------------------------------- ----------- --- (Complete in Duplicate) -------------------- I This Permit Expires 1 Year From Date Issued Date Issued -__-__ /G.� 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 49. JOB ADDRESS A OCATION-_-. _ - _ -. � f�� _° �• /�� Owner's Name----- ----------------•----------- •----------- -------------- Phone------------------------------------ Address........... _- �>. o �. = , -- -- ---------------------------- Contractor's Name yr _- A '' t ''`- --. ------------------------------------------------------- Phone."a -....... t.-... --------------------------- 19 Installation will serve: Residence' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ t Other ❑ --__ Number of bedrooms . � t Number of living units: � _-_ Number of baths __-"--"- Lot size ._ --.----_�-__"-_. _ 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 lay Loam p Clay ❑ Adobe❑ Hardpan ❑ 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------- -----------------FSize --- f!_____'. :Liquid de.fh-------------------------Capacity--------------- ------ Dispos Field: Distance from nearest well..- '-6_-Distance from foundgtion------- --_-.-.Distance to nearest lot line-_--------- Number of lines----------- Lengtn.of,cach 4ine_T's` (__'-._______.Width of french----- `-r r Type of filter material__. -- -_!_ Depth of filter material-------jj__f'__.__-Total length------��---------------------------- �t: Distance to nearest well--/6740 from foundation---_ f- -.......Distance to nearest lot €ire--.-.---�_- ] Number of pits--------/----------Lining material-----5�1?--------.Size: #er- -, a �------Depth___/'_P---------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-.-.- --.------.Lining material----------------------- ---- C Size: Diameter---------------- ----- ------ : - --- ----------LIgold Capacity------------------- �.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------.__--_-_--------_--.-_----..----.-. ❑ Distance to nearest lot line--------------------------------------------- Remodeling ----------------- -----------------------Remodeling and/or repairing (describe):-------- - - ------ -------- --•------ ---"------------- , -------"---------------------------------------------•-----•-------- ---•---------------------••---------------------------------- -------------•------------------------------ ------------•-------------------------------------------------- ---------------------------------------------•--------------------------------------------------- ---------------------—-----------------::------------------ ----------------------•- --------------------------------------------••- ---------------------------------------------------------- I hereby certify that I have prepared this application and,+ha+ the work will be done in accrdance with San Joaquin County K ordinances, State laws, and rules and regulations of the San_Jc a quin Local-Health District. (Signed) -------------------------------------------------------- ---------- ++war and/or Contractor) By----------------------------- = :�y ---- `--=- (Title)--------------------------------------- ------ ---------------- [Plat plan, showing size of�Io , location of system in relation to well b! ui€dings, 6+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------rte' ------------------------------------------ i -� DATE-- k+�-w��- ------- --REVIEWED BY BY---------------------------------------------------------------------------------------------------------------------------- DATE------------'--------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:_- ------- -------------- ---------------------------------------------------•---------- -----------"---------"-•"-------•------------------------------- -------•-•---------------------•-------------------------- ---------------------------------------------------------------------------------------------------------------------------------------•-------------••----- ---------------------------------------- -----------•-------------- -- -- ---------------------------------------•--------------------------•------- -------------------------- -------------------------------------- ---------------------------------------------------------- ---------- ------------------•-----------------•-- ---------------------------------------------------------------------- ----------------------------- FINAL INSPECTION BY:.. Date 6----�- S'r---- ---------------------------------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton 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 i.p.CC.