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FO FFICE USE: - -------- ___a - APPLICATION FOR SANITATION PERMIT Permit No. .. . ' ------ --------- ----- " ,: (Complete in Duplicate �- Date Issued _____,"-_�--6y ---""-.------_---_--_ ."------------------------------._ This Permit Expires II Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit o nstruct and install the work herein described. This application is a. n compliance with County Ordinance Nc TION- QT _-_fir -_4 �e- d�vC 4" JOB JOS ADDRESS A D LOC w r / ? ,?'' " Owner's Name - Phone. Address..._..---- � .•••- Contractor's 'Name.. ---------------- ------ -- --- ------_M Phone........ Installation will serve: Residence File"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. -- N er of bedrooms __ -Number of baths Lo+ size _____ �� ---_____""__________.___._ Water Supply: Public system ❑'�Community system ❑ Private ❑ Depth to Water Table .5�ft. - a Character of soil to a depth of 3 feet: Sand ❑ Gravel [:] Sandy.Loam E] Clay Loam ❑ C1 y-0 Adobe g�—1 ardpan ❑ Previous Application Made: (If yes,date_____--------------1 No � G Na New Construction: Yes ❑ 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_• ______Distance from foundation__/d__------Ma`ria --=----- A [� No. of compartments_____ ~:K-1..__---SSi-ze_,1`_� - �_.----.---Liquid depth---�lyr.___-- ___Capacity__,"'��' Disposal Field: Distance from nearest well_.-T -_Distance from 'P /* to nearest lot line.__/..." Number of lines-- --- __^.. ------___--Length of each line__`�!_�_..�------___.__.Wicith of trench ___.""__.___._--_-_.- Type of filter material__= n��l. _ Depth of filter material__.` -� Total length----- e-Q_ � C. i Seepagp,l Distance to nearest well____._._____- Dis ance from foundation_/. _!.___.Distance to nearest lot line_1 �__. A - �` Number of pits------ __________-Lining material__1�� Size: Diameter o, '__f.__..___Depth__-- - __ _ ►f___-" Cesspool: Distance from nearest well----____------_Distance from foundation__._--------.------ Lining material----"--_--_-__________________"""__. ❑ Size: Diameter-------'----------'------------- Depth ------------------ -------------------Liquid Capacity---------------- -•-gals. -___._Distance from nearest building..... _--.--. Privy: Distance from nearest well------------------ -------=------- - - g-----------------------•--------- � ❑ Distance to nearest lot'ii6e'___"".________,.--_ Remodeling and/or repairing (describe):-----_ ---------- --------- ---•--- -- ------------------------------•-•----------------- ------ ---'------- , 1 hereby certify that;l'haye repared this application and that the work will be done-in accordance with San Joaquin County ordinances, State laws,•,a d es and re-ulatio _of +he San Joaquin Local Health District. - --- �-' -------- - -- ' ----�=��-- -----'-'-------------------- ------------------'-------.....,_-,-.--(Owner and/or Contractor) {Signed------------------- -- (Plot plan, showing size of lout ation of system in relation to we"uildings, etc.,-can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--.----'----- ' ' '= -------------------------- ------------------ DATE-----,_---------- - ----------------- ' REVIEWEDBY-'----------- "--------- -------- ------' =------------------------------------ DATE...----------------- ----------- ------------- BUILDING PERMIT ISSUED------_------------------------- ------ --------------------- ' --- DATE Alterations and/or r com nations: _ •----------------- ,7d -� ._. `IM ------ - - - ------ ----- e ----------- =-2d-r� ----- ------ --- - �- �a ..6�---rte�,��,�-- - -- -�•-� �- ,' FINAL INSPECTION BY:------' ' -------- --- Date---- ------ -------- --------' ' ----------'-'--'------ ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 1 Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 9-59 3M 3-•63 F.F"1213- ' 4