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FOR OFFICE USE: --_----.-_----- - - - - ---------- APPLICATION FOR SANITATION PERMIT Permit No. ------------ ------- - ----------------- ---- -- --- --------------- (Complete in Duplicate) pp Date Issued _________________________________________________________ --,This*ermit 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 herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------G�_- I-Y,:�-------------- l.J ------------- - �'C N / ��y,,Q - - T--------- ----------------------------- Owner's Name---------V-E_-�•---------- r r� 1 5•--------•------------------------------- -- ---------------------- --------- Phone-.M ........ --- Address------------------------- Contractor's Name-----` ...... �11 �r - '•-------•- -----. Phone------------------------- Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: Number of bedrooms __7--Number of baths _1___ Lot size __ 's: _____ _/_c. + __j____________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _W/Y ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 5' ardpan ❑ Previous Application Made: (If yes,date---.-------.--------) No [Lj,-41'ew Construction: Yes ❑ No Pr-FHANA: Yes ❑ No's'' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material .._____________________-_---____..__________- ❑ No. of compartments--------------------------Size-- `---'----------------------Liquid depth------------- - ---------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- P ❑ jjy,;ot4. Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- S . Type of filter material-------------------------Depth of filter material------------------------- length__._______________ _____________________- a Seepage Pit: Distance to nearest well- __Distance from foundation___ _t______.Distance to nearest lot line__.-r........... Number of pits......)--------------Lining maferial-_`_'__'/'O�/'4Size: Diameter-_.__. .....Dept h---------Z4---------------- Cesspool: Distance from nearest well-________________Distance from foundation.------------------.Lining material--._______________________________-._ 6 ❑ Size: Diameter--------------------------------------DepthY---------------------------------------------------Liquid Capacity-.-------------------- -----gals. Priv Distance from nearest well--------------------------------------------------Distance from nearest building - �b ❑..- Distance to nearest lot line-------- --- ------ ----------- ---- ------- ---------------------•- '------------------------------------------------------------------- � C�`n r y /� / /y � ______--. Remodeling and/or repairing (describe):----�� ------� �,±�--- -- ---- --- - ��--�--��, _��_---=----------------•----------____-- t� -- ------------ --- ------------------------------------------------------------------------------------------------------------------ - - ----- ------------------------------------I---------------------------- --------------------••-------•---------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 Joaquin Local Health District. } (Signed)------ �2 --- 0,0-n-9-4)-------------------------- - --- ---- ------------------------------------------------------------------(Owner and/or Contractor) ti By:-------------------------------------•-•--------------------------------------------------------------------------------------------(Title)---------- -------------------- ---- - ------ i (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 on APPLICATION ACCEPTED BY ---�5----- ------------------------------------•--- DATE---------- ------------- REVIEWEDBY--------------------------------------------- ----- --------- DATE----- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------- -------------------------- Alterations and/or recommendations:------ ------- ------ ----------- ----------------------------------------------------------- --------------------------------•------------------------------- ------------------------ --------•---------------------------------------------------------------- ----------------------------------------------------------------------- ----------------------------- ------•--------------•---------- ------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.-L`' ------- - --�-------- ------------------------- Date---rte_=d_- . .- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-59 3M 3-'63 F.P.CGI. _ f