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FOR OFFICE USE: x$a-- q ----------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. 1. �. _. ------------ ----------------------------------------- -- (Complete in Duplicate) - � Date Issued This Permit 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 herein described. This application is made in compliance /with County Ordinance No. 549., , JOB ADDRESS AND LO A ION_ 1 -13----W (/J �': Owner's Name---------- ------------•- - ----------- - - ------ Phone------------------------•----------- ------------------- Address------------•........ ---- ------ ...... 1" -- --------� - ----- ------ --------------------------------------------- Contractor's Name----------------- v--------------------------------------------------------...--------•-----...... Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms .1---- Number of baths -------- Lot size --------r- --•_____________________ Water Supply: Public system ❑ Community system N) Private ❑ Depth to Water Table ........ 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-----------_--------) No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest we{I_//Y _ __Distance fr m °undation �Material r'_ '� // � � / xNo. of compartments_--_-..-- .----------Size...... .... _______________Liquid depth-------4-t�-.-------_Capacity..../_o7�a-_--_- \ Disposal Field: Distance from nearest well/OZ/1—Distance from foundation.,rYe_ ........Distance to nearest lot ...... (� Number of lines_________ _ __ Length of each line______ 1 `�� �r 9 11 ;7-----Width of trench f: Type of filter materiaVat,. _. ._._ epth of filter material-__--_--1�---------Total length........4&......................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- 171 _-- _.--_-----_❑ Number of pits---------------_--.--Lining material----------.------------Size: 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 nearest building------------------------------------------ 171 Distance to nearest lot line--------------------------------------------- ------------------------------------------------------------- ---------------------------------- Remodeling and/or repairing (describe)---------------------------------------------------------------------------•--------------------------------------------•--------------------------•---• j ------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- (�Q ---------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------- p -------------------------------------------------------•-------------------------------------------------------------------------------------------------- --------------------------------------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la , and rules and re tions of the San Joaquin Local Health District. (Signed)-------------- - ------(Owner and/or Contractor) By:--.................................................................... -------------------------------------------------------------(Title)-----------------------------------------...---------- --------- (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---------------------- -------- ----------------- --------------------- _- ------ DATE................ � i ----------------------- REVIEWEDBY-----------•----------•------------------------------------------------•----------------- . ........... DATE-------( ..✓ BUILDINGPERMIT ISSUED---------------------------------- -----------------------------------_--- ------------------ DATE------------`------------------------------------------------ Alterations and/or recommendations------------------- ------ --- ---------------------------_- ---------------------------------------..........'------------------------------------------ ------------ --------- ----------- ------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------- -------------•-- - -•-----------•---------••-----•------------------- -------------------------------------------------------------- ----------------------------------•--------------------- ------------------- --------------------------------------------------------------•- --------------------------------------------------------------•------------•---•-----•--------•---•--------------------- -------------------- ----- -- ------- -- ------------------------------------------------------------------------------------------------- 67Z� /I FINAL INSPECTION BY--------- --------- ------- --•� -� ('— Date - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 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 8-59 3M 3-'63 F.P.CO.