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FOR OFFICE USE: ----------------------------------------------- ------- -------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -/ _ (Complete in Duplica'e�.�" s4puz' �O / r� --- -- -- -------- This Permit Expires 1 Year From Dafe Issued Date Issued .____f__7. nss- f7a -�-0 Application is hereby made to-the San Joaquin Local Health District fpr a permit to construct and in `Il the work herein described. This application is made in compliance with County Ordinance No. 549. r r JOB ADDRESS AND CATIIOON_ ZP- -- fir- `�----- 4--.----- , ------ Owner's Name_==__ ._ � r. Phone Address----------•---_- Y- 1 Contractor's Name_ _ ____ _________ l -- �--------------------------------------------------4----------- -- -------------------••------------------ -- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living,units. _.�____ umber of bedrooms _3___ Number of baths b �0 g, Number f_--av Lot size ----/_?a._-'---- Water, Supply: Public`system ❑ Community system ❑ Private•B Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam M Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date............._.-___) No M 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.) - F ' Septic Tank: Distance from nearest well_•S�Q________Distance from foundationlal.________.Moterial s. No, of compartments----,2,-----_---_-------Size_/j9,t 9'tr_-___Liquid depth____-�4.___._.--.__-__-Capacity_/ ------- Disposal Field: Distance from nearest well C19.-.__q_Distance from foundation-/«'-............Distance to nearest lot line_4�_--____ Number of lines,____._---_ _ ____Length of each -----------------Width of french----el-_V..___________________ Type,of filter m teri�l _ _Depth of filter material___ -----------Total length_,A-___ t_-8--_____________________,- Seepage Pit: Distance to nearest well----------------------Distance from foundation__________________.Distance to nearest lot line----------------- ❑ '-'Number of pits--(-------------------Lining material--------------:---------Size. Diameter---.----.-.------------Depth------.---.---------------------- • � l Cesspool: Distance from nearest wail-----------------Distance from foundation____________________Lining materia)--------------._-__________ ❑ Size: Diameter--- I ------------------------------Depth----- ----------------------------------------------.Liquid Capacity----------------------------gals, Privy: .. - Distance from nearest well___________________________ __• --------------Distance from .nearest buildin ❑ . Distance to .nearest 6t line.-------------------------------. -�=h:;-- ---------------------------------- --- ----�---------------�---- - --------�---------- Remodeling and/or repairing (descrbe):--------------- _ _ -•,--- "y°�. --- -------_ t � , // t ----------------------------------------------- --- ---F------ --------------- ----- - A60 �P e r �`` W _,r,---_ F ------------------------------------:------- ---------------------------------------------------------------------------------------------1)------------------------------------------------------ --------- I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. F (Signed) :------�-1---L------ ----------------------------- --------------------------------------- - ------------------(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). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY "-------------- ---------------------------------------- DATE--- REVIEWEDBY------------------------------------------ - ---- --------------------------------------------------------------------------- DATE------- BUILDING PERMIT ISSUED------------- ------------------------------------------ - -------- DATE--------------- Alterations and/or recommendations: //n ------------------------------------------ ---------------------- ------------------------------------------------------------ -------------------------------------------------- ---------------- --------------------------------------------------- ------ ----------- ------------------ - --------- - -------------------- ------------------- FINAL INSPECTION BY------------------ -- ------ Date-----------------1 t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street 3tocklon,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B•59 3M 3-'63 g,p,C Q.