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FOR OFFICE USE: ---------------- ___________________.___.__. -------------------------- APPLICATION FOR SANITATION PERMIT Permit No. x ------------------------------ -------------- (Complete in Duplicate) �j This Permit Expires 1 Year From Date Issued Date Issued __�_T_S-__ ___ Application is hereby made to the San Joaquin Local Health District for a permit to construct an� install.the work herein described. This ap licatipri is-_madeFin-com liance with County Ordinance No 5 9, JOB ADDRESS AND LOCATION ( ----------y---- ---- --- ;------------------------------------------------------------- Owner's Name----1 . ----�U �--------------------- ---------------------------- ------ Phone------------------------------------ Address-----•-•----- _•,/------a�! Contractor's Name_,i(I fi t �� 1-------------------------� !Phone_/ --. _------------------- Installation will serve: Residence ] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ w Number of living units: �----- Number of bedrooms __J___-Number of baths __I___ Lot sire __ _ k64—P------------- Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table 7j_-__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy L 3am ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan Previous Application Made: (If yes,date____________________) No .� New Construction: Yes No ❑ FHA/VA: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: 11 _ —(No septic +ank-or cesspool permitted if public sewer-is availabI `within 200 feet.) z y � + -1 �{ �� Septic Tank: Distance from nearest well---a�__---..__Distance fro n�'foundation___:/_b_________Material__ _ --__._.__ No. of comp _tom._ artments.... -----------------Size__ ____. -.(------------Liquid depth------------------------Capacity-? ---- Disposal Field: Distance from nearest well._o�'Q-------Distance fro foundation----I ............Distance to nearest lot line__c�__'_____ Tl Number of lines-------/---- ---- g--_ -- Length of e h line------- �d---------------Width oftreneh__�_'�_t'______________-."- Yp �-°i: p I r material-----/-�".........Total length__4-P_--- -- i+ Pit: Distance ftloenearestrFwlell__r�p____ --D stance fro' ' foundation___1"41-______._.Distance to nearest lot lineJ7----------I ® � Number of pigs g __...___Size: Diameter__aX ' `_% ----�------------- Linin material-- -�Q- ---Depth----f- ----•-------- ------ Cesspool: ----- j L Cess ool: °z�a Diameter nearest well====-------------DDi Distance fro) foundation__--__-__________..Lining material--, � ❑ p - ----------- ------Liquid;Capacity----------------------------gals. ❑ Distance to nearest lot line___________________________________ I "-- Distance from nearest building------------------------------.___.____... Privy: Distance from nearest well______________________ _!1 --------- --------------------------------- Remodeling ------- -------------------- I ------------- -- Remodeling and/or repairing (describe):------ -------------------------------------- ------------------------------------------------------------------------------------------------ ------•--•"-----•-------------------------------------------------•------------------------------------------------- f-------------------------------------------------------------------------------- ------------------- ----------------------------------------------------------------------------------------------------------------- -- ------------------------------------ ----------------------------------------------------------------------------- I------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that a work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaqu Local Health District. (Signed}_ _ -. ------ '' �G - - (Owner and/or Contractor) a I _ Y• == -----_-- = ---------------------------(Tit e)-- ------ ------------------------- ------ =.------ (Plot plan, showin size of lot, location of system in relation to wells uildings,,etc., can be placed on reverse side). n FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY,,�_. ----------- ------� I DATE--.-,7113- ............................. REVIEWEDBY--------------------------------------------------------------------- °-------------------- -------------------------------- DATE-------- BUILDING PERMIT ISSUED--------------------------------- DATE Al+erations and/or recommendations: t'------------------------------------------•------------------ •-------•---•------------•-------------- ` --------------•------- III ------------------------------------------------------------- -- ------ ------------------------------------------ ; ---- ---------------•-------------------- ----------------------- FINAL INSPECTION BY:... ----------------- I Date------ --- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street, 11 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California i Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CC- �l:l 1 i I('I