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FOR OFFICEUSt: �, F �`� 4' APPLICATION FOR SANITATION PERMIT Permit No. .: ,�� -/ (Complete in Duplicate) - -------- ---------- --- -------------- Date Issued ____._ ------- ___6 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 hiescr' I This application is made in co lianc with unty Ordinance No. 549. l 'OATION � -- {� d -JOB ADDRESS A D 24--- ' Phone---------------------------------- .47 } Owner s Na -- - r =Address------ . --- - ---------------- •- - - ,. Contractor's Name------- Y - ` ` �- - ----- ------------- Phone M Installation will serve: Residence_ Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Wi v Number of living units: _ .c__ Number of bedrooms ._______ Number of baths _.__-_-. Lot size ._____X�•_---G` �4 : .---------•-------------- Water Supply: Public system ❑ Community system ❑ Private �Ipfh to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa y Loam lay Loam ❑ Clay F-1Adobe E] Hardpan E3 Previous Application Made: [if yes,date---_----------------) No New Construction: Yes No ❑ FHA/VA. Yes ❑ No r-`.,TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public'sewer is available within 200 feet.) � t Septic ank: Distance from nearest well--- Distance yfrom fpundafi�ion---- -------- _ _.Mateal_______ ____ ----------------- No. of compartments------ ------------- Size F x1 ---Liquid dep h-----5------------------Capacity ' pispos field: Distance from nearest ,w,c�II_-__c __`____._Distance from foundation--- _!__..-------Distance to nearest lot line Number of lin( le Length of each line______ V- ___r,_____-Width of trench.... _- -----� Len gg - - - --- ------------ Type of filter material of filter material______�p!_-.-______.Total length.....-.1-� ----------_____._..__-. t Seepa Pit: Distance to nearest well----10_0--------Distance from f99undation____ Distance to nearest lot line_________________ \ Number of pits------I-------------Lining mate rial-_, .?&----Size: Diameter-------- p jCesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material--------------..-_______________---_ ❑ Size: Diameter---------------------------_---------Depth----------------------------------------------------Liquid Capacity-------------------------_-gals. Privy- Distance from nearest well-----------------------------------_-------------Distance from nearest building------------------------------------------ Distance to nearest lot line._______--__. ❑ --i ------------------------------------ Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------=-•------------------•-•----------•-----• ----------------- ------------------------------------------------------------------------------------------------------------•-•------------------------•------------------•-•------•------• ---•-•--------------------------------•------- -------------------------------------------•-------....------•------------------------•--------•--------------•---------------------------------------•-•---------------------------------------------••---------------------- VJ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, Stat laws, and rules and regulatio s the San. Joa in.Local-Health District. (Signed)--- A -------------------- caner or Contractor) �Y= ------ --------- ---------------------------(Title)----••-•----------- -------------------------------------------- (Plot plan, showing size of lot, location of system to relatio o wells, buildings, etc., can be placed on reverse side). \� FOR DEPARTMENT USE ONLY w ( APPLICATION ACCEPTED --____-_-_ - ._ - - REVIEWEDBY--------------------- --------••---•----•-----------------------------------------------------....------------•----------•--- DATE----------------7--------•---------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------•---- I I Alterations and/or recommendations:--------•------------------------------ - --------•----------.._..---------------------------------------------- r- ------------ --------------------------------------------------------------------------------------------------------------------------- 1 l ______________________________.__.____.___-.__._-_.._-____________---._.__. FINAL INSPECTION BY:.. r_: t_v i -------- Date-- •. = `' ��==- ---------------------------------•-----•---- M � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ava. 300 West 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 F.P.Co.