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FOR OFFICE USE: _ o - -------------------- ------------------=----- APPLICATION FOR SANITATION PERMIT Permit No. , -7L ----------------- ------- - ----------------------------- (Complete in Duplicate) _ -' Wvv • Date Issued ------------ - - lpetYear From Date Issued -----�-- Application is hereby made to the San Joaquin Local Health District for a permit to construct t and in II the work herein described. This application is made in compliar! with County Ordinance No. 549- E JOB ADDRESS AN LOCATION1tG° 1r� (c--- a1 �-�- �1- Owner's Name ---- -- - ----- cr'�,,-u ----------------- Phone - - --- -------- Address ! = a- I--•---------------------------------------------------------------- Contractor's Name------------ a -x�.�.�V9------ ------- -------`�'---- ---.-- --`--------•"-------•----------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other [I Number of living units: ___I--- Number of bedrooms Z.- Number f baths __ - Lot size ____ _ _ ___ ______________________ Water Supply: Public system E] Community system El Private Depth a Water Table _ ft. Character of soil to a depth of 3 feet: Sand E] El 0 Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within-200 feet.) w, ,s. _ v T ''- Septic Tank: - Distance from nearest well-----------------Distance from foundation------------------- Material-------------------------------------------------- - ❑ No. of compartments--------------------------Size----------------------------=--_Liquid depth--------------------------Capacity--------------- ' 1 1 Dispos ` Field: Distance from nearest we{i---,,,�®_-.-.-Distance from foundation____ �__________-Distance to nearest lot line___ate___`_____ Number of lines___________ Length of each line-------.50- f_--__--_--Width of trench------- ------_------------ ` Type of filter material-_ -A_-----Depth of filter material--------lf_.........Total length -------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_______.__:___._= ❑ Number of pits--------------------_-Lining material Dameter----------------- ---Depth -_----,--------- -.--... Cesspool: Distance from nearest well-----------------Distance from foundation--_----------------Lining material-_-----------------.-__-._---------- ❑ Size: Diameter--------------------- ----------------Depth----------------------------------------------------Liquid Capacity---------------------------_gals. Privy: _ Distance from nearest,well-------------------------------------------------Distance from nearest buiid;ng-----------__---_____________---_-.-___ ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------- ------ Remodeling and/or repairing (describe)-----------=--------------------------- ------.......-----------------------------------------------•-------------------------------•------------------- ---------=--------------------------------------------------------------------------------------------------------------------------------------------------- -------- ----------------------------------------- r --------------------------- ---------------••----------------------•------------------------------------------------------------------------------------------------------------------------------------------------------ ' -------------- -- ---- ------ -- - -------------------------------------------------------------------------------------------------------------------------------- I hereby certify Mthat d rules prepared thisoapplication and that the work will be done in accordance with San Joaquin County ns of the San Joaquin Local Health District. �. r , (Signed)------------------ --------------- - -------------- --' d/or Contractor) P By------------ = i ----- ------------------------------------(Title)------------------------ = .-=-------- (Plot plan, showing size of lot, location of syste in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----lxl//o--- -' -- --------------------------------------------------- DATE-- REVIEWEDBY----------------------------------------------------------------------------------- ----------------- -------------------- DATE----------------------------------------------------- ------- BUILDING PERMIT ISSUED------------------------------- --------------------------------------------------------------------- DATE--------- -------------------------------------------r - Alterations and/or recommendations:------ ---- --------- -------- -------------------------------------------------------------------------------------------------•- -----. 1 --------------------------------------------------------------------- ---------- ------------------------------------------------------------------------------I------------------_-----------------------------=------- F i FINAL1NSP:CTION-BY: W- - -------------------- Date------------------ -------- - �` w -' ' SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E.Hazelton Ave. S00 Web Oak Street _124 Sycamore Street 205 West 9th Street Stacktonr California Lodi,California Mantecar California Tracy,California £5 9 REVISED 8-59 3M 3-'63 F.P.CO.