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FOROFFICE USE �- --------- ----- ----------------- -------------- ------------------- ---------------- ------------------- APPLICATION FOR SANITATION PERMIT of Permit No. ----------------- ------------------------------- ------- (Complete in Duplicate) 11 /J ref Date Issued ------------ --- This Permit Expires 1 Year From 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 Ord• nce No. 549. JOB ADDRESS A (p LOCATION____- -- ✓lc ---- ---------- �C Owner's Name--------- -- -- - _ ) r .. Phone,ti - --�� /-(�-!� Address----------------�. •-- ----- - --- ----iv- ,- ------- --------- --------- - - ------------------ Contractor's Name_-_-_ �f� �� '1>`'� P_Iv �✓ . Phone- Installation wifl serve: Residence MXartment House Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: -- ____ Number of bedrooms-3- Number of baths ___Lot size Water Supply: Public system [❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe*XHardpan ❑ 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.) Seoc.Tah0 Distance from nearest well-----------------Distance from foundation-------------------Material-----_------------------------------------------- J "No. of compartments-------------- ----------Size---------------------- ------Liquid depth--------------...........Capacity skl Distance from near t weft- �--Distance from foundation___LQ-........Distance to nearest lot (r- Number of lines___ �f - - -- - ---Length of each line_-- --QQ----------------Width of trench------ Ty l pe of filfer material- s LS �* T __Depth of filter material _..__Total length____________________Zcv--------- W 4 Seepage Pit: Distance to nearest well---------------A----Distance from foundation-------------------Distance to nearest lot line__.__----____-_- W ❑ Number of pits----------------------Lining"material--------- ----------...Size: Diameter----------------------Depth-------------------------_ Cesspool: Distance from nearest well___--_____---___Distance from foundation-------------------lining materia)------------------------------------- EJ Size: Diameter --- Depth----------------------------- ----------------------Liquid Capacity---------------------------gals. b Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------- -__._. ❑ Distance to nearest lot line Remodeling and/or repairing (describe):____ --------------- -- -- ----------- ---- - 1 ------------------------------------ -------------------- ------------ f -- - --------------- -------------- ----------------- ---------------------------------------.----- I hereby certify that I have prepared this application and that the work will a done ' accordance with San Joaquin County ordinances, 5tp 1ys, d rules a d regulations of the San Joaquin Lo I Health Distri Vk (Signed)___ 1 By:----------------------------- ---- ---------- ----------------- ----- - --- � - ---- -- --------(Title)--------------------- - --- --------- - ---------- - (Plot plan. showing size of lot, location of system in relatio wells, buildings, a ., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY----- ---- ---- - -------- DATE_ -:- --- -------- --- --------- VIEWED BY--------------------------------------------- -------------------- ----------------- ------------------------------ DATE--- --- UILDING PERMIT ISSUED---------- ------------------------------ -------------------------- DATE. --------------------------------- Alterations and/or recommendations:---------------------------------------------- - v+�� ------ - ---� - -- ------------------- ----- ------- - 7 --- -----t------- ------- -------------------------------- .... -------------------------------------- - ----------------------------------------------- FINAL INSPECTION BY--............. ---------------------------------------------- � Date------- ------------------ --- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California HS 9 REVISED 9-59 3M 3-•6 F.A.CD.