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FOROFFICE USE. 6 --- - - -- - - - ---------- APPLICATION FOR SANITATION PERMIT Permit No. _.,1_9z9 -------------------------------------------------------- om ate to Duplicate) - - This Permit Expires 1 Year From Date Issued Date Issued . �/ �-3 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 CATION"__.. . �,� _- _,pQ" " " _. 64-z-- ,. .---- ------ + ----s -- ----- Ph AddressOwner's Name_ 7r---------------- --------------7 Contractors Name --- ------ .. ; Phone--------- •------------ Installation will serve: Residence Apartment House ❑ CommercialTrailer Court ❑ ❑ Motel [:1 Other ❑ Number of living units: __1____ Number of bedrooms 1!-_ Number j--- baths Lot size --------- —•----•----------------------- Water Supply: Public system F] Community system F] Private Depth to Water Table __ ____ ft. Character of soil to a depth of 3 feet: Sand E].' Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe[-] Hardpan E] Previous Application Made: (If yes,dafe__..%--------------I No ❑ New Construction: Yes 0 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) J - Septic Tank: Distance from nearest'well-_______.__.._":Distance from foundation____.__--_-____.__.Material------------------ ------ ------------------------ ❑ No. of compartments---------- ------------ Size---------------------------- ---Liquid depth----------------- ........capacity----------------------- Dispos Field: Distance from nearest well___50------Distance from foundation-----1..Q__""___.Distance to nearest lomat- line__r3;_,__ .._.. Number of lines____.-_-_- � - • ----------------- Length of each line---------- of trench--...... -----,--�----------_"-•-- � Type of filter4maferial Jepth of filter material____�_�-----_."._Total length______.._3-�----------------�.--- x Seepa a Pit: : Disfance to nearest well-----/0-0--_--_Distance from foundation---1p-__.-------Distance to nearest lot line__ �_:___._ (C1 Number of pits__.___I--._._____-Linin material__..,. � p /o . 9Z../'!r_$izE: Diameter---- ! .----"--Depth----- -- ---- ----------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________________ ❑ Size: Diameter-------------------------- ----------Depth------------------------------------- -- ----------Liquid Capacity--------------------------.gals. Privy:-_ Distance from nearest well___----------------------------------------------Distance from nearesf building____".______--_____..________------_---... ❑ Distance to nearest lot line_________________ q Remodeling and/or repairing (desciibe):-------- - --- ----- - " ------- - -------- ----/ �-� --------- ----------------------------"-----------•-•----------;•---------------------------------------------------------------------------- ---- ---------- 1 --------------------------------------------------•----•---------------- --------------------- ---------------------------- -------- ------------------------------------------------------------•---------------------------------------------------------------------------------------------- - ------------ I hereby certify that I have pre'par d this application and that the wo will be done in accordance with San Joaquin County ordinances, Sfafyiglvs, and rules and gulations of theSan},Joaquin Lo,(alfilealth DI frict. l40 (Signed) ` - -- --------- Ow or Contractor) '. BY: %r a -----------------------------(rite)--------- - --------------------------- ----------------------- t (Piot plan, showing size of lot, location of system in relation wells, buil Ing , can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----- - ------ -- -------------------------------- ------------- ------ DATE--- ------17J� ------------------------------ REVIEWED BY------------------------------------------------------------------ ---------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------"------------------------ ------------------–-------------------------------------- DATE---------------------------------- Aterations and/or recommendations----------------- _--------------____ ----------------- ---------------------- ---------------------------------------------------------------------------------------------------•------------------- ------ ---- ------------------------------------------------------------------------------------------------- ----------------------------------------------------- - --------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------------------------------- ------------------------ ------------------------ ----------•-------- - -------------------- ---------------------------• ----- ----------------------------------------------------- FINAL INSPECTION BY: Fr..G..-, Date"._ _`---. _'.(---_ ------------- --------------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.CD.