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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ._..1.. 3z-- 4 -- --- -- ------------------ ----- -- , (Complete in Duplicate) �l/yq -------------- -- ------- -- _ This Permit Expires 1 Year From Date_Issued Date,Issued ------- _)1/3 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. ------. Th_.. _ T { JOB ADDRESS AND LOCATION..._____.. ___4------ _ -------------------------- Owner's Name----fix _� // // •- Address - ---------------- Contractor's Name / �_ .: -�" -------- --- =----- •----------------------- Phone .3.' . +� 1 . Installation will serve: Residence g Apartment House E] Commercial E] Trailer Court E] Motel F1 Other ❑ Number of living units: .____ Number of bedroom's xg--- Number of baths _ .. Lot size ( _ /SO---------------------------- Water Supply: Public.system. Community system ❑ Private ❑ Depth to Water Table SD ft. I Character of soil to a depth of 3 f�et: Sand ❑ Gravel E] Sandy Loam E] Clay Loam ❑ Clay ❑ AdobeK i Hardpan 11Previous Application Made: {If yes,date_____________________} No E] New Construction: Yes El No ElFHA/VA: Yes ❑ No ❑ V, k TYPE OF INSTALLATION AND SPECIFICATIONS: ! , (No septic tank or cesspool permitted if public sewer is-available within 200 feet.) r Septic Tank: l3istanee from nearest well l_/ _Distance ftom foundation__ _--_._-_.Mater[al__ -----------------------------_ --�----. No. of compartments..__ _ Size_ ___ ______________Liquid depth_.._.__ .._ G t � , qCapacity Dis osal 1 field: Distance from nearest well................iDistance from foundation--------------------Distance to nearest lot line-_---__----._-_.. Number of lines----------------------------- ____--Length of each line------------------------------Width of trench----------------------------------- Type of filter M�aterial------------------------Depth of filter material----------------- 4* Total length------------------------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line------------------ r-,. ... .�«,.....,......,,..--� �.. ❑ 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 ❑ Distance to'nearest lot line - .~ ------------------------------- -------------- P, ----- - P . - --------- ------------------------- . Remodeling and/or repairing (de gibe);_ � i�1 _Cllf/g..------ Fd-• ---•-•--------74_L(__.---- /T/ !----------- ------=------- =-------- ---- ------------------------------------------------------------------------ -- -------------- ---- . L '. ------------------------------------------------------------------------ k -- I hereby certify.that I have prepared this application and that the work will be done in accordance,with San Joaquin County ordinances, a laws, and rules and regulations of the San Joaquin Local'Health District. I (Signed)----- //t_. 7 4n---------- ----------- e -------------- ----------------------------- -__(Owner an / r Contractor) - / = r TBy:-------•---•----•-••- (Plot plan,.showing size.of lot,.location of system in relation to well uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY----- ---4'_7_7_7""�` ------------------------- REVIEWED BY ----- , DATE BUILDINGPERMIT ISSUED------------- -- --`--------'-------=-------------------------------------- - ----------------- DATE----------------------------------------------------------- Alterationsand/or recommendations:---------------------•---------------==•----=-------------------------•----------------------------------------------•-------------------------- ---------------------- ----------------------------------------------o- }-- 4 C ' ----- ----------------------•-------------------------------- --• ------- -------------------------------------------•------ I t 1 I i FINAL INSPECTION BY:-------- Y------- -------------------- Date � z -� SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Hazelton Ave- 300 West Oak Street C t% 124 Sycamore Street—, 205 West 9th Street tockton,California �" Lodi,California ; Manteca;'_California Tracy,California CS 9 REVISED B-59 3M 3-'63 F.P.CC.