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FOR OFFICE USE: ------ -------------- ----------------------- _ APPLICATION FOR SANITATION PERMIT Permit No. ..!.LlL.. .__...7 - -------------------- ------------------ -------------- (Complete in Duplicate) Y 2 / ..- This Permit Expires 1 Year From Date Issued Date Issued ___. _.__� fc 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 w__ith.®County Ordinance No. 549. QQ _ , JOB ADDRESS AND LOCATIO _ aic.z. _ ---..__- D �x.•�._.--- -------------------------------------------- Name - ----------- Phone-- - ------ ----------- - ------------ Address_..•-•--•------14.0 't f ------------------------ --------- -----•-------------•--------------------..---- r Contractor's Name-------------- --------- -- - ----- - ---•--- - ------------------------------- Phone----------------------------------- Installation will serve: Residence Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: __f--_ Number of bedrooms--- Number of baths -1---- Lot size ----------------- ------------------------------------------ Water Supply: Public system ❑ Community system ❑ Private [?r/ .o Depth Water Table __._.._. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel F] Sandy Loam [Clay Loam ❑ Clay ❑ Adobe❑ 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.) Septic Tank: Distance from nearest well_________________Distance from foundation--------.-----.__-_Material------_._--_._..__.-_._-.._.------..-----_____-. ❑ No. of compartments--------------------------Size------------------------ ---Liquid depth--------------------------Capacity-.--------------------- Disposai Field: Distance from nearest welL__s0."_.Distance from foundation-____h.f___ -.Distance to nearest lot lin y------------ ---Length of each line----- Width of trench--.._-.-Z------------- -------- Number of iines_____________.�A. _ - Type of filter material---.l A,---"' --Depth of filter material--_.._r --------._.Total length---------- _______________________ 0 5 Distance to nearest well-----`F'0.f-------Distan'c^ee from fo ndation----_LP_F-_.__Distant P to nearest lot li;e__S j_.___.. Number of pits._..--_/-_.__-_._._Lining material�t_a., ':-Size: [�icR�s#er__ --_ _...__.Dept h-----10-_-.-----__-..._-__-- Cesspool: Distance from nearest well-----_----------Distance from foundation--------------------Lining material--.---------------------------------- 171 Size: Diameter----------------------- ------------- Depth--------------- ------------- -------------------Liquid Capacity_. ----------------------gals. Privy: Distance from nearest well _----------------------------------------.-----Distance from nearest building-------_-__--_.___.._._.___--_.._._._._... ❑ Distance to nearest lot line- ------------------------------ - -------- - ----------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):------- - - . - - -- -- -----------------------------------------------------------------••----------------------------------------- 1 ---•-------•------•------------•---- ----------------------•------------------------------------------------------------------------------------------------------ --------•------------------------------.------ ----- ------------------------------------ ---------------------•------- -----------------------------------------------------------------------------------------------------------------------------------------------------. I hereby certify that I have prepared thi application a that the work will be done in accordance with San Joaquin County ordinances, St laws, and r s and regula �ns o the S Joe�n.LooaF~#af altl�District. C � �r. -- (Signed)-•-_ -- _ .-- ---- ---� "�Crw�7er and/or Contractor] ---- ----- Title (Plot plan, showing size of lot, location of system in relation t ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------ ---------------------------------------------------- DATE-- 6 -- -------------- OV REVIEWEDBY---------------------------- ---------------------------- ------------------------------------------------------ DATE----------------------•-------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------ ------------------------------------------------------ Alterations and/or recommendations---------------- - ------------------- ---------------------------------------------------------•----•---------- -------.-----------------•-------------------- ---------------------------------------------------- --------------------------------------- -------------------------------------------------------------------------------------------------------------•-----------------------•------------------ -- ------------------------ --------------------------------- ---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- � ` �� FINAL INSPECTION BY:- ------------------ Date_-.-1``! - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Na:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED a-59 3M 3-'63 F.P.CO.