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FOR OFFICE USE: �� 2 ----------------- --------------- ---- ---------- ------------ ....................... ......... .......... APPLICATION FOR SANITATION PERMIT Permit No. --- . ...-----........ ................... .... (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to constrct and install the work herein described. This application is made irk co�m�p iane With County Ordinance No. 549. baa-ADDRESS AND LO ATIO p L/CY/1y.- fAf" _I!� - .,---•--------- Owner's Name..... _J�G ! - ---------- ---- p^ t .. Phone...... - Address--- . .. . ar!..... ---- .. .... ------........ Contractor's Name-----��•�-a---f'"`•---- -- ........ ......................................... Phone.......-----------4---........ t Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. Number of bedrooms . . Numbe�r o baths .__r1�Lot size --- .A....................... Water Supply: Public system ❑ Community system ❑ Private [ Depth t Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑'I Hardpan ❑ Previous Application Made: (If yes,date-----------.........) No ❑ New Construction: Yes ❑ No ❑ FNA/VA: Yes'❑ No❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ( septic tank or cesspool permitted if public sewer is available within 200 feet,) ler Septi ank: Distance from nearest well .elli,...& Distant rfr � fourioatiory......-C'P!.....Mater'al ....--. .. } ...... No. of compartments.. . ........�-.Size... _.__...--- .�y� ,!Liquid depth......_j�G r......._.Capacity.- Dispo�S Field: Distance from nearest Distance X�.....Distance from foundation..�.0...__....Distance to nearest lot �ne..S.....-.. j [e� Number of lines....._.ac...._..... Length of each line.._�t�J............. Width of trench....- 9-0-6. 7 � -- Type of filter material___ -__ - . -r_-_.Dopth of filter material...... ........Total length__.__G` 5r. ................ eep Distance to nearest well-----pd...........Distance from foundation...-...4 L'.......Dotance to nearest lot line..... ........ `❑ Number of pits-------L__._...Lining material.....JA?-------Size: Diameter.9_7AP"- �Depth.....f: ................ l Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material._r.......................... ......... ❑ Size: Diameter------..............:...........Depth..- ------- ----......------.---............Liquid Capacity-- -----•--....gals. Privy: Distance from nearest well...................::...._�_._....---.._.._.-..Distance from nearest building:........-..c....-.---....---------- ❑ Distance to nearest lot line.----...................i'_.._....-----------------------------•----•--....---......-.......-.....................................- I - Remodeling and/or repairing (describe):........_-. M______- _-Y .. .........................................................................ra.............................. ...f t.....—.................._y-....-........---. .................................... .._.___-..._............._.----._..... .....-__--._—._..__...__.._.._--.............---.- u:.,._;..y....-....__.,----------------._............._......__-_....__...._.___-_____.. I hereby certify that I have prepared this application,and that the wa kRwill be'.done in accordance with San Joaquin County ordinances, State I , and rules and.regulations of the $an Joaquin Local Health District. s j ( y (Signed) - ..-...... - ---- - ------ -- --------- By: and/or Contractor) By:-- ....... . . .... - - ----- .................(riitle)------ ----__....... ... ... (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------- ....... ..... . ------------------ ...................------------....... ---------------------- REVIEWEDBY------------------........................---_.......... --------.....---------........--------............... DATE------------------------------------- = -�—:n BUILDING-PERMIT°ISSU-ED. =.:.--•-----------c. -> - ---' - ----• - DATE--m - - ................'' -- _ .. .r: 1 -- `-- f: D E / Alterations and/or recommendations:......................... ----------------------------------- _....,-...........'........................................----.................... ..........................................................•.......................---.................................---......-..............................................................--.................-----• ...-`•----..........................-.............-.......... ................................................................................................................•...............-........ --.......................................................-----..........._..----.___--------------__.....------------'......----••.....--------.....---•-----._..---------------------'-'---------------...------ FINAL INSPECTION BY:...II�G """''� �x. - Date. G .......... -- SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E.Hamlfon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,Californio Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 5M 3-'63 F.P.Ca.