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�� F �FFJ.CE USE: . � t� � •� ------ --------- -'"" APPLICATION FOR SANITATION PERMIT Permit No. ....-.f-_I_ ----- - ----- ------- --------------- ---- (Complete in Duplicate) Date-Issued --- ................... ------------------------------------ . . This Permit Expires 1 Year Frorn 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,a lication is made in compliance with County Ordinance 54 . JO ADDRE55 AND C TION !!-i/ Pte' � If ---------------------------- Owner's Name------- --• - - ------------ -- -------- --------- Ph ------------------------------------ Address---- ------------------------ Address---- one---------------------------------- .� -----------•------- Phone Name ----------------------------------------- S t. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ > " 1 : Number of living units: _ -_ Number of bedrooms -,Z_ Number of baths _.!__ Lot size _466KIAP------------------------------ _ Water Supply: Public system vllcommunity system ElPrivate ❑ Depth to Water Table _4J1'6ft'. Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9j,-14ardpan ❑ Previous Application Made: (If yes,dote------------------t-) No ❑ 1."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 T k: Distance from nearest well-----`' "'-__Distance �j m/f�o�u,r�ation__.__��.__._Matepial__"e-(/��____.._ ___. .� No. of compartments--.--�---_-_______Size_4�_��-__.___Liquid depth___�I. f Capacity___ __ Disposal field: Distance from nearest well......------Distance from foundatio .__/4,3p -_.._Distance to nearest lot line__S_._....c� Number of lines_________.. . _.___. Length of each line.._�.Q_�__ Width 'of trench.. __ __�-------------- ------------------- Ty -------- ------t '' Type of filter material .Depth of.filter material___��_______--Total __________________ 0. See�g it: Distance to nearest well---- .r7_-------Distance fr m fo ndation--_f .___._Ai tante to nearest lot ------------ mate Number of pits-------/----------Lining rial. ie __.5ize: Diameter_ Cesspool: Distance from nearest well-----------------Distance from foundation....- --_. -inmg i ater ._.___.___.-- __-------. ❑ Size: Diameter----------------------------------- `Depth------------------:-------------- - ----------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_------.--__-----.-.-.._._..__..___... ❑ Distance to nearest lot line.----------------------- -------------------------------------------- ---- ------------- ---------------------------------------- 4 4 Remodeling and/or repairing [describe): -; � -- -----------•-------- -- - 4 ----------------------------------------------------------------------------------------- -------------------------------------------------------F-------- --------- ---------------------------------------- ---------- -------------------------------------------------------------•----------- -----------•------------ -.----------------------...---------------------------------------------------------------------------------------------- --------------------=--------------------------------------------------•--•---------------•-----------------------------------•-----------------•----------------------------------------------------------- ------------ 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 nd regulations of the San Joaquin Local Health District. (Signed)--------------- - --------------------------------------------'--------(Owner and/or Contractor( hy:---------------------------------------------- ----------------- ---- { Title W. (Plot plan, showing size of lot, location of,syste in relation to wells, buildings, etc., can be paced'on reverse side). FOR DEPARTMENT USE ONLY, / APPLICATION ACCEPTED BY--------------------------- V DATE----- ---------- � �REVIEWED BY-------------------------------- ------- --- -------- ----- - - --------------------------- RATE-------------- BUILDING ------- ----BUILDINGPATE f -- ------ PERMIT ISSUED-----°------- � . -� = - Q ATE---------------------------- ------------------ - �Alterations an/or recommendations:- _L ------- ------------- f ------------------------------------------•----------------------------------------------•----------------------------------- = FINAL INSPECTION BY:Z_/_ .---r300 ------ - ----- Qate - -------- --- JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ma:elton Ave. st Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California California Manteca,California Tracy, California ES R REVISED 8-59 3M 3-'63 F.P.CC.