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FOR OFFICE USE: -------------- --------- APPLICATION FOR SANITATION PERMIT Permit No. _•1.. /..-.---- ----- .(Complete in Duplicate) Date Issued �/I ---'` ] _ ----------------------- ------------- This 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 L0CATIONfi&/&4_1JZV- _ _ t`�.__ �►q Owner's Name__, � r ----- --------------- --- -�--}---------,----- -- Phone----------------------------------- Address--------------- ......f -- . .. /1-4(- �----- - ------- 11- --- f ------ Phone Contractor's Name {� e ----- Installation will serve: Residence F-1 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [l� Number of living units: ---L Number of bedrooms -" Number of baths ---t-__ Lot size ----------------------------------------- ----------------- Wator Supply: Public system ❑ Community system ❑ Private fff Depth forWater Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay [ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date__-----------------) No ❑ New Construction: Yes :E] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if,public-sewer is available within 200 feet.) Septic ank: Distance from nearest well--_/_�Q____Distance, rom �ounda�ian___:�p________.MaiaV______________________________•___._____-__.__. No. of compartments-- --------------Size_ _x___t�_ -,X__J7 squid depth--------- ---------Capacity--t]--7_— Dispos i Field: Distance from nearest well.-�W. .._Distance from foundation__L_P__.._._____.Distance to nearest lot line------ -I_f____ Number of lines__________::�_ -----==--------Length of each line______-0_-__--or--------Width offrench------2 -t-if -------------- (0 110 I Type of filter material-------SIC--------Depth of filter material____1!?-------------Total length------t&C?__._----------.--------- 411 x 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_---4_----------Distance from foundation--------------------Lining material---------------------__---_---_______ ❑ Size: Diameter--------------------------------------Depth------------------------------- --------------------Liquid Capacity- ------------------------gals. it Privy: Distance from nearest well------------------------------------------------- from nearest building. --------------------- 4. ❑ ----------------------------------------- Distance to nearest 4ot line-'---------- --------- - - ---------------------- --------------- - .' �.. .: (",,Remodeling and/or repairing (describe):--------------------------------- ------------------ F -----------'-•------------------------------------------------------------------------------------------------------------------ •= T ----------------------------•--------------------------•----------------------- --•------ r--------------•---------------------------- ------------------- ---�-= --------- ------------------•---------------------------------•------------------ ------------------------------h__S -nM_ --uin_'-- --------------- - -----'-- 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. I !. Si ned {4y --- -- ---- ---------------------------------------- and/or Contractor ---------------------------------- s- (Plot plan, showing size of lot, location of system in relation to wel , buildings, etc., can be laced on reverse side]. '��"FOR DEPARTMENT•USIE ONLY h+~ - APPLICATION ACCEPTED BY----. -- DATE -(s- i REVIEWEDBY ' ---------- - DATE----- ----------------------- ------------------------------ �` ------------------ DATE---------------------------------- --------------------------------- BUILDING PERMIT ISSLjEb--------••------------------------------- -'----;"---�-------=-------------- --' ''' ------ `-----•------ ---------------------------------------- Alterations and/or recommendations:------------------ - ---------------- a ------------- ------------ - -- _.. _ �=��-:�-. - FINAL INSPECTION BY:------ a "'° s I Date.- �' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazetton Aro. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F5 9 REVI9 EG 8-59 3M 3-'63 F.P.CO.