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FOR OFFICE USE: ' --------------------------------------------------------- - //// // . APPLICATION FOR SANITATION PERMIT Permit No. ..!6..v-._e..7 ------------------------- ---------- f ----------------------v ::__--- ------ - (Complete in Duplicate) Date Issued __________ _______----_._ _ _ -. .--.I-..-.---._-. This Permit Ex ires 1 Year From Date Issued .r Application is hereby made to the San Joaquin Local Health District fora permit to construct and"nstall the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION � -----yk` t �'� -- ==---------- Owner's Name------ ---�----------------------- ---- ------ ----- ---._. Phone---------_---- •---•---'--------- T Address_______________ Contractor's Name---- --- -s •---•--•---•-------------------------------- Phone---•------------.--------=--------- Installation will serve: ;Residence $ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms --I--- Number of baths_-.-- Lot size __ -------------------------------- Water Water SuPPIY� Public.system Ej Community system ❑ Private ®lDepth to Water Tablet-V - ft. I Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El. Clay Loam.® Clay ❑ Adobe ❑ Hardpan.® Previous Application Made: (If yes,date........... ......) :No 1E New Construction jYes "ar,No [] t. 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 �o----------Distance. fromq f�aundation.._ 1A.._.-_.{.Material______________________________________ No, of com artments. -_ _ Size--&/t+ �:--Li uid de th___-. -:-:•..Ca acit IX µ Disposal Field: Distance from nearest w6ll�4a_--------Distance from foundation___ °_______.__.Distance to nearest lot line--- �] Number of lines------3----. g _________________ ___Length of each line----�1�__.,�Q'..._Width of f4rich Type of filter material _ ____Depth of filter materiaL___.C?"_._._.____.Total len g , ' _______________ S ' 7it: Distant to nearest we l-:-�0-------------Distance from foundation-__AR-----------Distance to nearest lot line--.S----------- Numb�o s------—------------Lining material__ .........Size: Diameter_ D�'_..ozc._.__Depth-./f------------------------- Cesspool: Distance from nearest well--------------- Distance from,foundation-,-- material___,__--.._.---.-------.---_--_-___- Size: Diameter--------------------------------- a�r. ' ❑ --'-Depth---=-----------=--------------------------=-------Liquid Capacity- - •--------------------•-gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.--------_______-_----_--________-. ❑ Distance to nearest lot line ----------- Remodeling and/or 'repairing (describe)----------------------- --------------------------------------------=---------------------------- --------------=------------------------------------- -----------------------------------------------------------------------•------------------------------- ----------------------------------------=-------- ------------------------------- ----------------------- -------------------------------------- ----------------------------------------------------- ----- --------------------------------------------- ------•---------------------•-------------------------------•----------------------------------------------------------------------- ----------------- ---------------------------------------------------•----------------- --------------------------------------------------------------------•--------------- ------•---- - ----------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and' rules and regulations.of the San Joaquin Local Health District. r : (Signed)---------__... --_ . .-- - -------------------------------- ---------------------------------------------------------------{Owner and/or Contractor t t By: = - (Title) - -------------.-. (Plot plan, showing size of.lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------------------- DATE_!/.-/4� k?. ----- --------- ----------------- REVIEWEDBY-------------------------------------- ----- ------------------------------------------------------------------------------ DATE-------------------- -----=--------- BUILDING PERMIT ISSUED-------------------------------------- ----------- -------------•--------------------------------------- DATE------ -- ------------------------------=-------------•----- Alterations and/or recommendations:--------------------- ----------=------------- -----•----------------�----------------------------------------------------- -- -------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------•------------------------------- •---- ------------------•---- ------------------------------•------------------------------------------------ ------------------------------------------ -------- '---------- ® ;` , -----------------------•------ -----•-----------•------------------------------ FINAL INSPECTION BY:......-- --------------•---------------- Date------ �`'L f� G•� ---------- - -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street - Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.CD. ..ti