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FOR OFFICE USE: s• � { ---------- ---------- r„-,--- APPLICATION FOR SANITATION PERMIT Permit No_ _ ______ �. ------------------%11--------------------- --------- ` (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 Orddiiinance No. 549. JOB ADDRESS AND LOCATION.------- 0 '! 4� - -- ------- --------------------------------------------------------•-• ----•"----------------•------------ Owner's Name ----------------------- --------------------------- -------------------------------------- -------------------------------------------- Phone /• � F—7 ^ •-------- ---------------- Address------------ --------------.Address------------ _ = - ----- �-------------------------------------------•------------------ Contractor's Name__ ��-------------------------------------------------------------------------------------------------------------- Phone- •-_--- -•-- Installation will serve: Residence ff-'Apartment House E] Commercial Commercial E] Trailer Court ❑ Motel E] Other El Number of living units: __/---- Number of bedrooms,-_____ Number of baths `-_-- Lot size ___ _ ._X_ _ '__________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _?____ ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date--------------- ----) No New 4 onstruction: 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.) Septic nk: Distance from nearest weIVI_0`7"(--Bistance from foundation---�_��-----.Material-_-�_---.__--_`_ No. of compartments-------_--- _______Size___ �X_ _--` .__-Liquid depth....�"�_--------------Capacity.. Disposal Field,: Distance from nearest II/VCr'~`�Btstance from fou/ndation.---�.�?/__ Distance to nearest lot ----- Numberline ��____ y Typoffillines material-___��-- -'Length of each line> - _____-7_ �----.Width of trench-_-__-j- ________________ b ___Dep#h of filter material____-� _--___--_dotal length----- d . ,} Seepage Pit: Distance to nearest well______________________Distance from foundation-------------------Distance to nearest lot line_-___--_.___.-___ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth----------------------------- -- o Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------______-- ❑ Size: Diameter-------------------------'---'-------Depth___----- ---- ---------- ---- --------- Liquid Capacity----------------------------gals. a Privy: Distance from nearest well ---------------------------------------------Distance from nearest building----------------------------------------- El --_-_____________-_______--_ -___❑ Distance to nearest lot line--------------------- ---------- ---------------------------------------------------------------------------------------- --------------- - Remodeling and/or repairing (describe):___-..______- 1 • Ii -----------------•-------------------------------------------- -------------------------------•---- ----------- ----------------•--------------------- ---------------------------------------------------- i I --------------------------------------r - ----------------------------------------------- -------------- ------•------------------------------------------------ - 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regulations of the San Joaquin Local Health District. (Signed)- -- ---- --- ----- -- ----- - ---------------------------- _(Owner and/or Contractor) _....� By ------------------------•----------------------(Title)---------------------- ------- (Plot plan, showing ize of lot, location of system in relatia o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....11<�e-------' s�� DATE_. y = REVIEWEDBY--------------------------------'--------------=---- ----- ---------------------- ) - ------- DATE----------------------------------------------------------- �-. ---- ----- ------- ----- QATE-------------------------- BUILDING PERMIT ISSUED_____ _____-----------------___ _ _ - Alterations-----------------------r commen ations:_. F r --1, --- i -------------- - �'-- fir ----- ---------------- air= =y+.r----- - --� -'- --X :,cr_ 7f.Yr_ �--�J-' '--- � '---• '''-------- -----•- —,1f� Y ---•- ---- � - c C3Q� �� FINAL WSPECTION BY:------------------------------------------------------ ------- Date----------- [ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hasellon Ave. 300 West Oak Street 124 Sycamore street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9-REVISED 5-59 3M 3-'63 F.P.CO.