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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..I ------------ -------------------------------=------------ (Complete in Duplicate) --------------------------- ------------- --- This Permit Expires 1 Year From Date Issued bate Issued Application is hereby made to the San Joaquin Local'Health District for a permit to construct and install the work herein described. C.—This application is made in compliance with County Ordinance No. 544. 40$— 13o.-13 JOB ADDRESS AND LOCATION Z;F0 .- u__�_'` I(c , C-------------- --------- : ' --- , !/ Owner's Name.- L7 == = =- -- --_..--- - Address-__ a5l /y -------- - - ---- ------------ Contractor's Name------ -- --------- `----- -- -----R------------------------------------------------------------•--- Phone....---•----._._..--------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I----- Number of bedrooms J_ Number f baths _1--- Lot size _-----._ � -�T ----------------------- ! Water Supply: Public system E] Community system [:] Private [Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam El Clay Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date---------------____) No ❑ New Construction: Yes ❑ No ❑ FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well__�_4.__---Distance from foundation------10__-----Material-----_.dexp_--�______________________ No. of com artments--____ Size. e re .S� Ca Capacity �-- P �------ --�--��--/r----=---Llqurd depth--------`/--- ----------- P Y•-•---------- ---- - Dispos Field: Distance from nearest well--�O______-._Distance from foundation--------r -__-_-Distance to nearest lot line--,5..... Sna I Number of lines----------2'---_-_ --_-- Length of each line------/-Od-------------Width of french---.'�-------------------------- Type ------------- ---- Type of fitter material---- _�----Depth of filter material_-.--�_-ly----------Total length........ -_---__----___-----.- to $eepa a Pit: Distance of pts rest w�_-/D .........LininrDteraaLe from founds ze:nDiam�ter_..��e�..to.Deathst-Iot line r�s�.,S-s---_ � f Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter Depth -_----- ----Liquid Capacity----------------------------gals. Privy: Distance from nearest.well- -----------------------------------------------Distance'*from nearest building----------.-----__----.-____----_------_. ❑ Distance to nearest lot line-=---- ---------------------------------------- ------------------==--------------------------------------------------------- ------------ 1 g Remodeling and/or repairing (describe):--------- =" ---------------------------- •-------------•--- ------------------------4_ ib ----„----- -- --------------•--------------I---------------------------- ---------------------------------------------- ------------------------------- =----------------------------•-------------------------------------------•---•----------------------------------- I hereby certify that I have prepared-this,applicaf ion and that the work will-6e done in accordance with San Joaquin County ordinances, State laws;-and rules and regulations of +he San .Joaquin'Lotal_,Health-District...; 1 (Signed} ------ -- ---------- -- ---------------------------- -----------Vi and/or Contractor) ---- --- - By--------------- - s . (Ti+le) --- �s----------------- (Plot plan, showing size of lot, location of sys em in rel�fion to wells; buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- �� -------------------------------------------------------------- DATE----- REVIEWEDBY------------------------------------------------------------------------------- <-------------------------------------------- DATE-----------------=_-•:-:•=- BUILDING PERMIT ISSUED------------------------------ -------------------------------------------- ------ DATE----- - Alterations and/or recommendations-------------- -------------- ---------- --------------------------•---------------------------•-- ------------------------------ ----------------------------•----- ------:--- ------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:------ ----------------------------- Date--. •`��' ` . .-�P. . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.1-40.