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FOR OFFICE USE: --------------------------------------------------------- ---------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -•-------- ------- ------ -- ----------------------- --------------- (Complete in Duplicate) C� This Permit Expires 1 Year From Date Issued Date Issued _________!_ _. / Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. p p JOB ADDRESS AND LOCATION._ffl tl -t.--- ----------------WL � �----- /._l � .---.._ ... Owner's Name-------. . n!---- -------- --- Phone---------------------------------- Address `� .-_ A-C.. _ ___.^' :------------------------------------------------------------------------ Contractor's -----------------•------------------------- -------------- Phone.-------------------•-•--..._ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer 4; c a Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms _- Number of baths -_/___ Lot size ---70+_;L-0-7____ --------------------------- Water Supply: Public system ❑ Community system ❑ Private IE Depth to Water Table .S?_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loom 4V 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.) Septic Tank: Distance from nearest well (� wel---d____�'Distance from foundation___/--------------Material------------------------------------------------- No. ___----------_---_--___._________.._.-______-. No. of compartments____ _ .____Size___ ' ___Liquid depth______ _______________Capacity- __..___� Disposal Field: Distance from nearest well_'+S_b_.__-Distance from foundation--------------------Distance to nearest lot line_•S�__.____- - 1[s Number of lines______________ ____________Length of each line__/ ''r_sl� _'__.Width of french---ttZc_v-__'-------------------- Type of filter materiaejfWV Depth of filter material___ __,__._Total length----/f Q_ __________________________ Seepage Pit: Distance to nearest well_---------------------Distance from foundation-______-___-.-___.Distance to nearest lot line____-_--.________ ❑ Number of pits----------------------Lining material---------- --- --------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well__________.__Distance from foundation--------------------Lining material,__--_._.______.______._______-__-._. 3 ❑ Size: Diameter - Dept ly ---------- -------------------------------Liquid Capacity----------------------------gals. Privy- Distance from nearest well------------------F_`________----------------Distance from nearest bu-iilding_-.-----_____.__________________________ Q ❑ Distance to nearest lot line- ----- --------- -------- ---------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------=---------------------------------------------------------------------- ------------------------------------------------------------------------------------------------}'------------------------------------------------------------------ ----------------------------------------------------- ----------------------- -------------------------------------------------• -------------------------------- -------------------------------------------------------------------------•-------•---------------- --------------- ---------I--------------- -----------------------•--------------- ----------- --------------------•------------------------------------------------ ------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an egulations of the San Joaquin Local Health District. (Signed)----- --------------- ---------------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------------�.._--------------------------------------------- =Y (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__ 1/ -- REVIEWEDBY------------------------- ------------------------------------------------------------------------- DATE------ -----------------•------------------------------.---- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------.. DATE--------- ----------------------------------- --------------- Alterations and/or recommendations:---------------------- ------------------------------------------------------------------------------------------------------------------•------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------- --- ------- --------------------------------------------------------------------------------•--------------------•------------- --------------------------------- Z� ------R--- FINAL INSPECTION BY: .. . •-- ------------ Dafie3.--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,kaxslton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,Collfornia Lodi,California Manteca,California Tracy, California E5 9 REVISED B-59 3M 3-'63 F.P.CC.