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F�'_ICATION FOR SANITATION PERS Permit No. .......... _.._-__ __- ... (Complete in Duplicate) f Date Issued 2 hj /O ----- - This Permit Expires 1 Year From Date Issued>�ri5.Pj ' --- --- Application is hereby made to the San Joaquin Local Healfh District for a permit to consfr "uel rsnd stall +he work herein descr bed. This application is made in compliance wifk C E _ my Ordinance No. 549. (9E._3 i c'-v/ y, r, ,7 2T r �C - �M `I/✓ // JOB ADDRESS AND LOCATION____-.- --- _--- ._ - Owner's Address < --,_ --- r - ------------- . - Contractor's Name .. / .. -ts[- .- .-•-s /''�"`-'"` --'� - .Phone -__- ._. .. �J__ Installation will serve: Residence ❑ Apar Ifff ent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �.t./, Number of living units: I--- Number of bedrooms --- Number of baths 1_-- Lot size -?.---- ------- .-------- ___- Water Supply: Public system ❑ Community system ❑ Private [r/Depth to Water Table x:''y 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__._______.I Noo New Construction: Yes ]! No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s sewer is available within 200 feet.) Septic Ta9kt Distance from nearest well-_J5-.0_..._Distance from foundation--_-.d.---.__.Material- ' _ _ ®/ No. of compartments__. -- Size-- 3_¢ -k_Ix'---.--_Liquid depth_.--.` , Capacity._- -G G-tj y �1 Disposal Id: Distance from nearest well_ --Distance from foundation_/✓'..----------_.Distance to nearest lot line...-_--,r Number of lines_-_-_--j----..-_----__.-.----Length of each line__-7._.-._r_F'57 Width of trench__.2_/---------------------� Type of filter material. /Q_____-Depth of filter material-_6? ___Total length__-_.r ' _-� Seepage Pit: Distance to nearest well_ '__.--_Distance from foundation Distance to nearest lot line---: _-_ .y '�i�i Number of pits- -f ___ Lining material i:-..'. - ._---__-Size: Diameter r_'____-_.Depth_ ,h _ - -_-..- tD Cesspool: Distance from nearest well-----------------Distance from foundation_____.........Lining material---_ ------ ---- --- ____-_ ' ❑ Size: Diameter Depth -----__---Liquid Capacity.-_-_.-_--__ ---__-_-----gals. Privy: Distance from nearest well __ __ - - _Distance from nearest building_ __ ---- - - ..._.i ❑ 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 laws, and rules and regulations of the San oaquin Local Health District. (Signed)- ------------.-------(Owner and/or Contractor) By:------ - ------- ------------------------------------ --- ----------- (Title) - -- --------- (Plat -----(Plot 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_ r. - DATE - -- - REVIEWED J' BY--------------- ------- -... - - - ---- --------- - ----------- DATE----- ---- -- -------- ---------------- BUILDINGPERMIT ISSUED------------------------------ ------- -- ------- -- - --------------- -- -- - DATE- _ ----- ---- -- ------ --------------- --- - Alterations and/or recommendations:- ---------------- ---------------- ------------------------------'-------------.--:----------------- ----..-----------. . ............................ _ ----_.._-------------------------........... -------------------'------------------------------------------------- ._---_..----------------------. --------------.......------------__- ----_.--------- -------------.......-------------------_....-.. -------- FINAL INSPECTION BY. 2 ` �, ; ' ._..-----. Date - - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazellon Ave. 300 Wesl Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi,California Manteca,California - Tracy,California ES 9 REVISED 8-59 3M 3-'63 FeZo.