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FOR OFFICE USE: ------ Permit lsg Permit No. ___...-... -_--- ------------•--- APPLICATION FOR SANITATION PERMIT --- - •• ---------------------------------------------- --------- (Complete in Duplicate) 1 w _ „r. Date.Issued ------------------------ - ------------- 1r �This�Permit•Ek irei"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. 4 JOB ADDRESS AND LO ATI N' � - .., � - •------------ f it - --- Owner's Name F -Phone--`----•-__. •--••---------.. _ ________________»_______.._.______._._.e.____..-.____.._..... Address ------- = ..� Phone......:~............. ' _---------- ---- Contractor s Name--------•--- .... ---- Installation will serve: Residence j�partment House ❑ Commercial ❑'} Trailer Court ❑ . Motel ❑ Other;❑ _ Number of living units: __ _. Number of bedrooms J--- Number of baths -�_.. Lot'size .:�A0P••��Q�-------- Water Supply: Public.system ❑ Community system ❑ Private 4?"Depth;to;Water Table ft Character of soil to a depth of 3 feet: ,Sand ❑ Gravel❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe Hardpan ❑ Previous Application Made: (if yes,date------ No ZK"'New Constructipn: Yes ❑ No jg,—_FHA/VA: Yes ❑ No gj.- — F TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Sentic T Distance from"nearest well________________Distance from foundation______-_....___-___.Material-------------------------------------------------- j No. of comps tments-=--------------------- -Siz------------------------ --------Liquid depth----------------------- Capacity V Disposal Field: l` ld: ' from nearest well------------------� Distance from• foundation__:-- ________' __---DWisitdatnhce to neare_s-fi lot_ line- �-_"__ _ of trench---- -- ------------ .Number'dklines--------- ------Length of each line....'------- ----------•- Type of filter matrial__________ --------------Depth of flter materia _ Toh__l-: __ ______________________________________ / to nearest to line---- Seepage Pit: Distance to nearest well----/ 1---- Distance frofoundatio:A ----- D-stpth ---------.- , erial___ � Siz�:'Dimter ------.DeNumber of its --_ _Liningmatae Cesspool: ❑ Distance from nearest well-________________Distance from foundation.------------------ Lining material--------I______________-______---_--. Size: Diameter--------•---------------------- ----Depth--------------------. -----------------=----Liquid Capacity------------------------_- Privy: ---------------------Distance from nearest well----------------- --� -Distan�cee from nearesf-building-__-------------------------------------------- -- -. ❑ Distance to nearest lot line-- ------------------- - ----- •---- ----.-_._------------•--------•-�•----=--------------------------------------------------- ---------- Remodelingand/or repairing de ` ' = -----------•-- ---------•------'------------- --- ------- ----•-----------•---------------------- - ..,.: t I hereby certify that I have prepared this application anJ-o-acluin that the work will be done'in accordance with San Joaquin County I � ordinances, State laws; and rules and regulations of the San ..Local Health District. li { er�r�or Contractor) (Signed)- ----- f '�'r v gib/+� -- - ----------4-- --------------- SY• ------------------- ------•--------- --- -" (Tttle)� � (Plat plan, showing size of lot, location of syste n.relation to walls, btaildings,'etc.,-cari'be placed on reverse side). FOR-DEPARTMENT USE ONLY ----------- ------------------------ APPLICATION ACCEPTED BY---- / - ---,�'�G4,�-------- DATE---1-�----��-r�----�'-6- ---------- -- -- x --- REVIEWED BY----------------------------- - '-- DATE =- _ BUILDING PERMIT ISSUED------- -------- ---------------- ---------------------------------------- DATE----------------------------- ----=-------------------------- Alterations and/or recommendations:==----- = =` == __:__.. __------=--- t ------ ------- --•---= ------= -------- r --- ----- ��----- �'j`'j f1 ' C� ��~ - F ------------------------------------------------------------------------ --------------------- \ (� FINAL INSPECTION _BY:47-_ Date - ( SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street . 300 West Oak Street ti 134 Sycamore.Street, 205 West 9th Street Stockton,California Lodi,California '�')Aanteca,�Callf�brnla 1 Tracy,California �9-9 REVISED e•38 F.P.0 D.SM 6.5E r