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>� FOR OFFICE USE: ' Permit No. APPLICATION FOR SANITATION PERMIT ------- --------------------- -- :.---:,:--------------. H {Complete in Duplicate] I 3 __:._. " This Permit Expires 1 Year From Date Issued 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. 54.9. f� ��! �pS-1�-O_O.( j� JOB ADDRESS AND ,�,L,/OCATION- Gr�'�:, ----------l� --------f� f �"`-"� •: Owner's Name------- !-�-1---- ---•- ---------------------------------------- -------=------_-----------------' Phone Address---------------------�r:------t�:. � ' Contractor's Name--�t��x. I ---- -----. Phone-----------_--------- - _:.b________._______ _____________________________ _ _________ Installation will serve: Residence d] Apartment Houser ❑ Court ❑ Motel ❑ Other ❑ ' r Number of living units: _I___'_"'Number_ _ of bedrooms�_.CN Number iof baths Trailer Co size - '� 0---------------------- Lot Wafer Supply: Public's stem ! 5 !` 7_�ft. y ❑ (;;Community system ❑ Private [� Depth to Wa#er Table _ Character of soil to a depth of 3 feef: Sand ❑ Gravel ❑ iSandy Loam ❑ Clay Loam MA r Clay ❑ Adobe ❑ Hardpan Previous Application Made: (If yes,date________________ ___) No 00 New Construction: Yes No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS. : r i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p m foundation____f_�___:__.MateriaL_.____________ ---- j Septic Tank: Distance from nearest well___.__�_____:Distance f�ropQ 1/--- �] No. of com artments_.._ -_____________ Size. _Z' -�_-___Liquid depth________ ..._______;Capacity,_IeZ °------ i i * Ari Disposal Field: Distance from nearest well---irA-------Distance from foundation____tP---------Distance to nearest lot line--- ._.._--- Number of lines-----i-4-------------------------Length of each line------ fft7T!_'___'__._.Width of trench...e2.f- -_.______________-._ YP p Y l------f-Q. -------Total,.length_-4ll --------------------------- Seepage Pit: Distancetonear stiwlell_._/. `-D stars e.-fromrf undayion____ '_____.Distance to nearest lot line---i�_r.______---- �. Number of pits----a-___-----------Lining�i e_rial! �____-Size: Diameter._.. -__________._. Cesspool: Distance.from;lnearest well-----------------Distance from foundation--------------------Lining material____..________._----___.________-____. ❑ Size: Diameter--------------"------- ------------.SDepth------- ------ --------------------..Liquid Capacity-----------------------------gaIs. �. Privy: Distance from'.;:nearest well--------------------------------------------------Distance from nearest building---,,-_;...____________________..._ ❑ Distance to nearest lot line- ---------'------- ------ ---------------------------------------------------------------------------------------------------=---------- Remodelingand/or repairing (describe):----------------- --------------------- --_------- ------------------------•------------------------------------- ---------------------------- ------------------------- ---------------•-- ------ r 1 t 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. II (Signed)----- - --------- -�--'��'�'------------------------'- ----------'--------'--------------=- -- -----'--------------------------------'---(Owner and/or Contractor) Title� -t. ; --------- y ..._ ------ ........................ sy------------------= ------ --;------- ------ ----------- ------- - ------- --;_-- ------ { 1 (Plot plan, showing size of,lot, location of system in relation fo,wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --------------------------------------------------- DATE---/A"- -4--1 ----------------------------- REVIEWED. BY---------------------------------'-----------'---------------- ----------------------------------------------------- ----- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------—--------------------- ----- DATE. ---------------------------------------------------------- Alterationsand/or recommendations:-------------------------- ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- -----•-•------------------------------------------------•--------------------------------- -------------------------------------------------------------------------- -----•-------------•"'------------------------------- -- . ---------------------------- - ------------------ ------------------ - ----------------------------- iFINAL INSPECTION BY:-'- - -- - - -' - -- - ------------------- Date------------------------ ----------------'--------------------------- `I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street St"kien,California ,I Lodir California Manteca,California Tracyr California ES 9 REVISED B-59 3M 3-'63 F.P.CC. it