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FOR OFFIC US ------------------- APPLICATION FOR SANITATION PERMIT Permit No. _.�..3....... - ..... --------------------------------------------------------- (Complete in Duplicate)II Date Issued --------------------------------------------------------- This Permit Expires 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. JOBADDRESS AND LOCATION.. .3 � -------------------•--------------•----------•----------------------------•-•---------------------------------------- Owner's Name = Phone Address----- !�j ------- ....... --------- Contractor's Name f --•----- - ----- -- h_'-..------------•----- Phone---_ Installation will serve: Residence g3"_Aj4artment House[] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __-I--- Number of bedrooms _-_ Number of baths --1----- Lot size _440P _lQd_--__----.-._-------------------- Water Supply: Public system ®'Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Q Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: [If yes,date-------------------.) No 91-1, New Construction: Yes [!r No ❑ FHA/VA: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: 11 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) , Septic Tank: Distance from nearest well--- R --Distance from foundation---0.............Material------- -----------/----- ❑/ No7 of compartments----- -----------------Size.-`&IC ----------t-Liquid depth__!-----------------Capacity-- ---- !-.. Dispo I .Fiel i Distance from nearest well-_--------------.Distance from foundation--------------------Distance to nearest lot line----------------- '� Number of lines------ ---------------------------Length of each hne�M---------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length---.-.-.-.._.-------------------------_- Seee/IpNit�•' Distance to nearest well------------------ Distance from foundhation--------------------Distance to nearest lot line--------.---.-..- r' ; Number of pits---------- ----------Lorin9material-- -------------------�ze: D'ameter-----------------------Depth---------------------- - ------ Cesspool material lV Distance from nearest well_----.--.-------_Distance from foundation--------------------Lining material------------------.-.-------.-..-_---. I ❑ Size: Diameter--------------------------------------Depth----------------------1)h--------------------------Liquid Capacity---------------------- Privy: Distance from nearest well--_------------------------------- -----------Distance tante from nearest building-- --.---.----.---_.--_---------------. ❑ Distance to nearest lot line-----------------------------------------------•- ---•--------------- ----------------------------------•--•----------------------------- I Remodeling and/or repairing (describe):---- - e I--�='-"" -------------••-------•-------••-•------------- ..............------ ------ -----------------------------------I-------------------------------------------- ---------------------------- - --------------------------------------•-..-..------------ -------------------------------------------------------•-------------------------------•-----=--`-------------- -•---- -------------••------------.--..---•---•------------------..------------------------ - --------------------------------- ------------------•------------------------------------------------------------- -----••--- -------------------------------------------------------------------------• --------------- I hereby certify that I have prepared this application and thatthe world will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local hiealth District. ------------ Owner and/or Contractor (Signed) ( / ) �h - By------------------ p�------------f`----i`------------ ---------•- ---- -- �-------------------(Title)-------------•-------------------------- ---- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY r{ APPLICATION ACCEPTED BY_----- ' --------•-------- -------••-11 -- ------------ DATE-----------�---4 ------------------ t REVIEWEDBY------------------------------------ --------------------•------------------------------------.--k---.-•------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-- I) DATE------------------------------------------------------------- datios::_ - - - --Alteraf ns d/or recomme ------------------------------------------. .......I---•------------------------------- i11 :,-_ C�� ------------------------------- -------------------------------------------------------------------•------------------------------------------ -- -------------- 0 ------------------------------------------------------------------------------------------ , --- ----- 1.k------------------•--------•---•---------------------------------------------------------- -----------------------------------------k------------------------------------------....-.-------------•-•--------------- FINAL INSPECTION BY:..-. - --s..... ----- Date--. J'"_ --- 5AN JOAQUIN LOCALJHEALT M DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktonr California Lodi,California Ma Let,California Tracy,California Es-9 AEvisEC a•59 r.P.CC.2M 5-60 1