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F/7R OFFICE USE: -------------------- i r ` ____________ __ _ _____ APPLICATION FOR SANITATION PERMIT Permit No. ....... .....-- --------- (Complete in Duplicate) c c, "'� - _-- This Permit Expires 1 Year From Date Issued 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. 544. JOB ADDRESS ANP, LOCATION_ .._. ----------- ------ Owner's Name__-_ _ <P-.444,41-�a ------.-_- Phone_ Address ---- --- - ----------------------------------------------------•------------------------------------------ ------------------ Contractor's Name--- -------- -----•--------- -Y- ---------------------------- --------------- --------- ---... Phone.:!-� _g407 Installation will serve: Residence l�( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: &AL. Number of bedrooms _3__ Number of baths __e? - Lot size --------_------_ Water Supply: Public system ❑ Community system ❑ Private>( Depth to Water Table'e/to ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: (If yes,date - ------ ) No New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 14Tank: Distance from nearest well.................Distance from foundation------------------.Material-----------------.---___---- No. of compartments---------------- - ---Size--------- ........ -----Liquid depth --------- ---- - -----.. Capacity------ --- r F' .__ ... --- -------- Id: Distance from nearest we ,S�.._.__Distance from foundation_.._ Distance to nearest lot line____ __________ er of lines--- YP / --- � P � �A+------ g - ----------- ----------- Type e of filter material- �_. _ De thLengthoff filternmlaterlal._/s To#althlen length of french------ /� Seepage Pit: Distance to nearest well--------------........Distance from foundation_._-___-_--__-____.Distance to nearest lot line_____......._..__ ❑ Number of pits... ...-...Lining material.--------- -- _-.Size: Diameter----------------- ----Depth-- -._.....:-------------------- 0 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 lire_ ----- ------------- ---- Remodeling and/or repairing (describe):---- ----- ------ _L - ---- - --------------------------------------- --- ---------•---------------------- --- --------- -----------_ -----•-----------------------------L--------------------------------------------- -- -- ---------------------------------------------------------------------- ------ ------ -------------------.....------ -------------------------------------------------------------- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, a laws, and rules and regulations of the San Joaquin Local Health District. (Signed} - --!--r$It------------ _ -- ------------ - ------ - - .(Owner and/or Contractor) * . + ----- ----------- By:-------------------------- -•------ -...... i .v - ,. {Title} (Plot plan, showing size of lot, location of system in reljffcartTo Wills, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY s br r` s DATE - ` - r ---------- REVIEWEDBY----- - -------- ------------------ --------------- --------------------- DATE-------- ------- ----------------------------------------- BUILDING PERMIT ISSUED------------- ------ ---------- ---------------- ---------------- -------------------------- ...... DATE------ _-....-- -- Alterations and/or recommendations:.------- ___........... ---------- ------------------------------ --------------------- ---------•----•--------------- ----------------------------------------------------------------- ---------- ------ ----- - ._ Y.. ----------------------•------- ----- - - - ------ -- ---- ------------------ -- --- -------------------- - - - FINAL INSPECTIONBY:.... _ — / —�- --- --<'r--L�<-=<- ---- -� -- - Date -------------- - - ..... - -- - --- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-S9 3M 3-'63 F.P.CD.