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FOR OFFICE USE: Q= ^---+O-4------------- ------ Permit No. APPLICATION FOR SANITATION PERMIT f--- -------------------------------------------- (Complete in Duplicate) Date Issued --------------_---------------------2----------------- This Permit Expires 1 Year From Date Issued l (p3_370---fS 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. p d 6,�`y�i/7� W. JOBADDRESS AND LOCATION.... !!l'U� ------------------`5-----••----------------------------------- ----- ----------------------------------------------------- Owner's Name--------1691-7....... �.----------------------------------------------------------- -- ---------------------------------------- Phone_T Address----------(`S`,-h'-2G -------•------•------------------------•------------------------•-----------------------------------------------------------------._...----------- - -------------------- Contractor's Name Name---� -,//I/ ------------------•------------------------------------------------------ ------------------ Phone-�AP____ l ---- Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ or Number of living units: --- Number of bedrooms -------- Number of baths /----- Lot size _7--f3r-A-F-3---------------------------•-------- Water Supply: Public system Community system [-] Private ❑ Depth to Water Table - - ft. Character of soil to a depth o3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: {1f yes,date--------------------f No Q] New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ((�\ r (No septic tank or cesspool permitted if public sewer is available within 240 feet.) SepticTank: Distance from nearest well_________________Distance from foundation--------------;,----.Mater'sal------------------------------------------------- ❑ No.-of compartments-------------------------Size-------•---------- -------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot � line ne______---._____-__ _._.Width of trench__________-___------------------------------- E] Number of lines___________________________________Length of each line_--______--_________---__. --------------------Type of filter material------------------------- of filter rratenaL---------------------Total length N See age Pit: Distance to nearest well—__--Distance fro dation__-.__ 6D - o nearest lot line S ----�-_-_-.__-_-_-.- �3,,- Deptn___---__-Number of'pits--------1-------------Lining material--- --Size: Diameter- _ r Cesspool: Distance from nearest well----------------Distance from foundation--------------------Lining material------------------------------------- 0 -------------- -----____-____.___❑ Size: Diameter--------------------------------------Depth--------------------- ---------------------------_Liquid Capacity----------------------------gals. (� Privy: Distance from nearest well ,-_,•..__________________„----------------------Distance from nearest building------------------------------------__.._. ❑ Distance to nearest lot line----------------------------- -----------------------------------•`------------�------------------ --------------------------------------------- T Remodeling and/or repairing (describe): - ---------1q ----- �s j `�-------- F`r.c h'------------------------------------------- ---------- ----------------------------•---------------------------••---------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- 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. ( wner and/or Contractor) (Signed)--- - ----- ------- -------- ------------------------------------------------------------- ------ -- --- -- ---•------------•----- -------- ----------------------------- -----------------------------------------(Title). - --- ----'------ ----------- ------------------- [Plot plan, showing size of lot, location f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY - ----------------------------------------------------------------- DATE-_/0 ------------------------------- REVIEWEDBY----------------------------------- --------- --------------------------------------------------------------_---------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------ --------------------------------------a---------------- DATE ---- --- ------------------------------------- Alterations and/or recommendations:- '.G^ �� ----Ci �------ -�� &V = -------------------------- ------------------•-----------------------------------------------------------------------------•-•---------------------------------- ------------------------------------------- ---...-•---------•---------------------------------------------------------- ---------------------------- --------------------------- -------------------- ---------•----- ------------------------------------------------------------------------•------------------------------------------------- I FINAL INSPECTION BY:_._l _.J..7— Date-. ------------------- -------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED 9-59 31A 3-'63 r'.P.00.