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FOR OFFICE USE: -----------=--------------------------- ---------- ---------- ------------------------------------------1. ---- ---__.__.._-_.--__________________._.._____.________--1. APPLICATION FOR SANITATION PERMIT Permit No. --/7s 3 ' (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made toy 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. JOB ADDRESS AND LOCATION___- - --'_ ---------- ----- - Owner's 'Name-------- -- --------IM '. -------•-------------------- - -- --------- --- - -------------------- - ------------ Phone--------------=--------------•-•- - Address--------------- = (a ------------------ -------- Contractor's Name--------- ---�r r. -------------------------------------------_-------•----•--- Phone--------------------•-••----------- .. Installation will serve: Residence Apartment House E] Commercial E] Trailer Court [IMotel ElOther ❑ I----Number of living units:!_�____ Number of bedrooms V.- Number baths _1`----- Lot size ------- -74-il--------------• - Water Supply: Public system ❑ Community system ❑ Private Depth ater Table ________ ft. s Character of soil to a depth o 3 feet: Sand ❑ Gravel ❑ Sandy Loam 2f Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Mader (If yes,date------- ---_--------J No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: k (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance f�Fom nearest well-__-_...._____--Distance :from foundation____________________M terial__._-________-_._ �d q - I f� flp -------------------- - Li ui eptly-.--`-`----� -- ------- Capacity----------------------- � ❑ No. of coin artments---- ----=--- ---------- Size.---=------•---=� - - - ---Liquid depth.-.--� .> .o � t 1 Dispo I Fieid: Distance fro}, m nearest well________ Dis;tance from foundation__ ..........Distance to nearest Iot�iine__.�?_ f - - Number of lines-----.___ .___ Length of each line----- s' f` Width of trench-_----------------- -______ 1 Type of.filter material- _% Depth of filter,material_____!_1t -_-_____.Tota! length------ ------_-__------- See pa a Pit: Distance t nearest well----- d -Distance fr m oundation -_ d-/___.Distance to nearest lot line--.!;F` --- ti. „ i` gp l __..___:__Lining material_ Size:Diameter____—?3 Number of'' its___._- �- - �,�--�---.Depth -��'o----- ------ Cesspool: r� Distance-fiom nearest well_________________Distance from foundatio,___--_..__..__.___..Lining 0 n F 1µ ❑ Size: DiarAter----- k ----------------- -------------nearest from,nearest building-' , ❑ " r 'I1; , g -------------------------------------- Distance to nearest lot line--- --------------------------- - = --------------- ----------------------------------------- Remodeling and/or repairing (describe):-----------------------------•---- -------------•-•--------------------•-•-- ------------------------= ------------------- ,Ill ------------------- ----------------------------------- - r.`_, ri _._ ,..� ... _ x..,. ------------------------------------------------------------ =------ --------- ------------- Play --- -------------------------------------- = ---------------------------------------- ------------------------ = I herebt I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, nd rules and regulations ofahe San Joaquin Local HealfVDistrict. r - (Signed)- -----f -------- ------- 4# ,I, --- ----- ------ - ------------ ---- --� ------------------ - -------------------- ----- ---- wn nd/or Contractor) BY .:.... --t--------... ' � Title---------- -------------------------- (Plot plan, showing size,of'lot, l6cation of system,in,r` ation to wells, uildings, etc., can be placed on reverse side). r „S ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._� < _.::�.: ------------------------------------- J; ------ - DATE----- REVIEWED-BY-----------------!!`-------- --=-------I- - --------- - ---------- - ---=--------------- DATE BUILDING'PERMIT ISSU.ED----- '------------------------------------------------------1`---- -------------------------------- DATE--------------------------- Aaerationsw and/i5i recommendattons------------------- ---------------------------------- ----------------------- ----------------------------------------------------- ' du - ---- ------------------------------------•- ----------- -------------------------- --------=------------------ -------------- Ili •- ---- ------ --------------------------------------------------------------------- ------------------=------------------ ----- ------- -•------------•-------------- -•------------------------------------------------------------------------` FINAL INSPECTION BY:- !L% --_----------- Date6 ............� . ---------- t3 SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REV-iSED 8.59 3M 3-'63 F.Rro. a�