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F R OFFICE USE: ,/ Ifl------- _-------; _. __ APPLICATION FOR SANITATION PERMIT Permit No. __ _--f.' d�• ' ---------------------------------- ---------------------- (Complete in Duplicate) Date Issued This Permit Expires 1 Year From 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. JOB ADDRESS AND L - ------------------------------------------- LO-CATION---- Owner's Name------------- _ ---------------------------- - ---- --------------------------------- Phone------------------------------------ .. � .� � -C ------------•- --- ----------- •--------------•--••-------Address { Contractor's Name = A , - = Phone__S h Installation will serve: Residence N Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-.f-- Number of bedrooms __,-__ Number of baths _�____ Lot size -----�t/__P- ___l_ �_--_______________________ I l Water Supply: Public:system ❑ Community system ❑ Private N Depth to Water Table _lP-___ 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 0 New Construction: Yes No ❑ FHA/VA: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet,) � 1 � Septic Tank: Distance from nearest -------Distance from foundation.____I ......Material------ /'39_____~_____________ IK No. of compartments-----"----zr--------Size--- fdk__ .Liquid depth------ `r_____-_Capacity__Aw----_-_____ disposal Field: Distance from nearest well._.j1W_`0istance from foundation_{,14 Distance to nearest lot line____/_:__ Number of lines____'_______`__ _ _____________Length of,each line_-"-�'�0.Width of french----- --P'-------__ i Type of filter material_-- j_Depth,of.fiiter material---1,,r-_-------- length__ _`_______.-----/_- Seepage Pit: Distance to nearest` well a_X�__---Distance.frop foundation_`:_AQ.......Distance to nearest lot line__.______.. U Number of pits-_ Lining material___sY/� °C-Size: Diameter- - Depth---- - - --- Cesspool: Distance from nearest well_________________Distance,frorn foundation---,.--:.____.__--- Lining material------------------------------------- < ' n ❑ Size: Diameter------ .----- u"-------- -----------Depth---------------- ----------------- ------- --------Liquid Capacity------- •------------------gals. Privy:' Distance from nearest well-------------------------------------------------Distance from nearest buiiding-----------------------------------------. ❑ Distance to nearest lot line------------------------------------------------------------------------------ ------------------------------------------------------------- �;, G Remodeling and or repairi,g (describe):- /�/ -, /--- l-`--c�GU_ �� S' -2 3 -- 2 ----- --------•--------- ------------------------------------------------ ------------------------------------ ----- i ----------------------•- ----------------------------------------------•----------------------------------------------------------------------------------------------------------------------- ------------------------------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ------------------------------- w and/or Contractor) gY� ----------------------------•-------------------------------------(Title) fa (Plot plan, showing size of lot, 1 tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY Z-Y 27 APPLICATION ACCEPTED BY---------- ----------------- DATE.../ � ' G --- --------------- REVIEWEDBY--------------------------------------------- -- ---------•---------------------------------------------------------------- DATE------------- ---------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------- --------------------------------------------------------------- DATE--------------------------------------------- --------------- } Alterations and/or recom endatio V _ _ _ _______________________________ --------------------- -------------------------------- ------------ ------- -------------------------------------------.------------------------------------------ ---------------------------------------- ----------- ----------------------------------- ....... FINAL INSPECTION BY:------. ----------- ------- - -------------------- Date....... 4" /�"� 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 ..EG 51 REVISED B-59 3M 3-'63 F.P.CD.