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1-UK UFFICE USE: ✓ ; ,.4;/-- PPLICATION FOR SANITATION PERMIT Permit Na. ..��..f._.... , ------------- ' (Complete in Duplicate) ! . 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. 549. JOB ADDRESS AND LO ATION- ...... Owner's Name-------- Address.................. - - --------- -- Phoned.1-..•--.�/ Contractor's Name-------- - ,ie!:�*,r-)5 /-/--_----;�� i-------------- Phone._ / �� 4 Installation will serve: Residence Apartment House [:] Commercial [:1 Trailer Court. C] Motel [:] Other ❑ Number of living units: .-_ ____ Number of bedrooms .'umber of baths __ __- Lot size / -- -----------` . .. Water Supply: Public system Community system E] Private ❑ Depth to Water Table-,g� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe - Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction:, Yes ❑ No FHA/VA: Yes ❑ No ❑ TY OFINSTALLATION AND SPECIFICATIONS: (N ptic tank or cesspool permitted if public sewer is available within 200 feet.) p an Distance from nearest w 11 Distance from foundation____•_-_______-__.Material ___________.._____..._. No. of compartments----•---------------------Size---------------------• ---_--.Liquid depth---------------- ------ capacity""--* posa Distance from nearest well_. _-Distance from foundation__...f,6*"___Distance to nearest lot Number of lines_______ _ _ _ ___Length of each line-_' --`A _-------_.Width of trench.__ �� Type of filter mafieria ___De th of filter material- - / I{ -------------------- Depth F Tota( length_._.. S .-----•.•••-- Seep ge Pit: Distance to nearest well 'L.-.-Distance g foundste: Diameter- �to nearest igf line__.._.__...... Number of pits___-.1______________ Linin matenal_)wx�'' ' ___.____.Distance from --- -- - -�- --`='":Size,: Diameter_.-•�-�-----...Depth-- --o��.a,�,------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------- material-------.--_______-__ Size. Diameter-------------------=---------=--------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ___________________________________________-----Distance from nearest building _ ❑ Distance to nearest lot I- e Remodeling 'and/or repairin ---------•---•-•••------------------------ ----- ti ---- -- - ` ��-------•-----------•--••-------------•--------•------...-------------- -------•-----------------•-----------------•--------- ---------•-------- --••----•------- ---------... -- ------------...-------------.....-----------•-•-----------------••------------•----------------...__._ I hereby c rtify that I h�prepared this application and that the work will be done in accordance with San Joaquin County ordinance St t laws, and rules and regul ns o the n Joaquin Local Health District. (Signed)------ .._ ----------A----------- n By:---- -- --------------------------------------•----------------...- Title __ ------------- By: __ ____ ___ - - -- - - -1�eW - (Plot plan, showing size of lot, location of system in relation tbuildings, etc. can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__________ _ ____ ---- - - --- -----------------------------------------••--=--------- DATE--- 1 ~. J• -- REVIEWED BY__. ---------- - ---------------------------------- - ------------------------- DATE...._ ------- BUILDING PERMIT ISSUED-------------•-•----------=---- •-----------------•--------------••--------------- •-•------------... QATE.-------------------•---------------•---------••----.._..---- Alterations and/or recommendations:___-__.._______________ -=lam`---C� 1._._ -... -�-- = ---------------------------•---------....... ---•------•--- --------------------------•------------------•------------------ FINAL INSPECTION BY:. -- --- ----------- Date f r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South ,California Strut 300 West Oak Stroh 124 Sycamore Street 405 Wool 9th Street Stockton, alfo CS 9 REVISED 8-99 01A 9-61 ATLAS Lodi,California Manteca,California Tracy,California