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FOR OFFICE USE: -=--------- ------------------- ---- ------------ APPLICATION FOR SANITATION PERMIT Permit No. __ _.__....d. _._ ----- ------------------------------------ (Complete in Duplicate) 11 ��--------------------------- _.._- This Permit Ex ires 1 Year From Date IssuedDate Issued .__�Af.___.- Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. l QD3 —C(00-1I ,E ;I JOB ADDRESS AND LOCATION =1 `� `r `'.-. '/ ------- ------------------------ Owner's Name------Z - II --------- Phone--------------- ------•---------- ------ ----------------------- ! -- Nama ---------li------------- Phone----------------------------------- Contractor's Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court Court ❑ N)otel ❑ Other ❑ Number of living units: J--__ Number of bedrooms ___�_. Number of baths J-- li Lot size __ _y-_ ---______------------------------- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 50 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (if yes,date___________ _____) No ❑ s New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: __[No.septic fank,or_cesspool permitted-if public sewer is available within 200 fee..} - -- — Septic Tank: Distance from nearest well_________________Distance from foundation___.',_____-- -----Material_____-__:_.._____.______. __.-.-___....______.. El No. of compartments-- -- ------------------Size--------------------------------Liquid depth-------------------------.Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation__--_!.__________Distance to nearest lot line--------------- ( ❑ Number of lines-----------------------------------Length of each line---------------I(-------------Width of french----------------------------------•- th of .. T Distance to n nearest material b'Q-_-______D stance from foundation__Iq----___-__Distance length nearest lot line_______._ Yp Seepage Pit: D s � � " � •] $ Number of pits_____-----__-______Lining material/1--v -_____._.Size: Diel meter------v-3_.'._..___.Depth-----A$7___________________ Y 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 line----- ------ ------=------------------- ----------- -------------------------- A. l Remodeling and/or repairing (describe}:------ r it ' ... -•-----------------------------------------------------------------------------------------------------------------------•- f-------------------------------------------------------------------------- -- ------------------------------------------------------- - • E ------ ------------------------------------- -------- ----------------------------------------------•----------------------------------------�--------------------------------------------------------------- ------------- ---------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan es a laws, and rules d r ulations of the San Joaquin Local Health District. [Signed)_ - _- __ (Owner and/or Contractor) ------ ------ ---------------------------------------------- BY=---------------------.-------------------------------- -----------------------=--------------- --------------------- - [Title)--------- ------------------------------ --- -------------- �P {Plot plan,showing-size—of lot,-location-of system in-relation to wells, buildings, etc.; }an.be placed on_reverseside).�side),___4 .y, - FOR DEPARTMENT USE ONLY �� DATE- -�b '-�,3 ---- APPLICATION ACCEPTED BY---- - --------------------------- - REVIEWEDBY--------------------------------------------- -----------------------------------------------------------------------1I------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------- --------------------------------I.�----- DATE.- s f4 --------------------------- `------------------------------ Alterations and/or recom--------------------------------------- endations'----------------- ------- - -------- --- ----------------------------------------- *: ------ ---- ----------- I • - .1 i ----- , � --- - -------- ---------------------------------------- ---- - ------- --------------- ----------------- ----- FINALINSPECTION BY------------------ - -•------------------------------------------ Date_) -------------•---------------•- -------------------------------------------- .i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F.Hatellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISED 13.59 3M 3-'63 F.P.ED. s._.'.�.