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OR OFFICE USE; -------------------- - ------------------ APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ----------------------------------- ---- (Complete in Duplicate) ------------------------------ ------------- --------- This Permit Expires I Year From Date Issued Date Issued _---0A- Application ---0A-Application is hereby made to.f I he 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. t. JOB ADDRESS AZLOCATION A:11� - --------- -------------------- ----------------------------------------------------- Owner's I _0),o Name--- - - --- ------ -• ------- Phone----------------------- Aciclress.,R-en)-o-------4�---�—�—, ------------ - -------- - -- ------ ----------- ---------------.1......------------------------- ---- -- - ---- Contractor's P Contractor's Name--------------- -- - -----: ------- ----------------------------------------------------- -------------------------------------------- Phone.1�4177�y Installation will serve: Residence )< Aperfmenf House El Commercia LTrailer---Court E] Motel El Other E] Number of living units: -/- ---- Number of bedrooms .9?.- Number of baths -Z- Lot size Wafer Supply: Public system E3 Co Immunity system private W Depth to Water Table 20- ft. Character of soil to a depth of 3 feet: Sand El Gravel E] Sandy Loam E] Clay Loam 0 Clay [I Adobe 10 Hardpan E] Previous Application Made: I If yes,date -------------------) No El New Construction. Yes ❑ No tZ FHA/VA- Yes El No [I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed,if public sewer is available within 200 fe"ef.) I Tank: Distance from nearest well_--__----------Distance from foundation--'% e ---- --------�-.Maferial No. of compartments----------- --------- i __Size--------------------------------Liquid depth. -----------Capacity------------ ........ Dip4,saF,Id. Distance from nearest weI16/151-Ap--* Distance from foundation.,#,01-D...... .Distance to nearest lot line-------------- Number of ------ Length of each line--A��4_'----__-----_-Width of french-----1:0-15V-1.1 Type of filter materiaL_ ei�"-Depth of filter mate -----Total length-------------------- -0------------- Seepage Pit: Distance to nearest well 41 re Jr -------------Lining-!_----Distance f om fQundation--411�..------Distance to nea st lot line------ Number of pits et - maferiar��,;M-Z---Size: Diameter. -----------D epth-.--,07.s Cesspool: Distance from nearest well-----"-I__..--_--Distance from foundation------------------- Lining material__._---_ - F-1 Size: Diameter--------!---------------- ----------Depth-------------------------------- - ----------------Liquid Capacity---------------- '-gals. ----------- Privy: Distance from nearest welt-------------------------------------------------Distance from nearest building_-------_----.-----------.------ 1:1 Distance ito nearest lot line___------------------- ------------------------ Remodeling and/or repairing (describe):_--.-__------_ ----- - ------------------------------------------------•------------------ ---------- ---------I--------------------------------------- ------------------------------------;------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- ------------------------------------I------------------------------------------------------ ------------------------------------------------------------- ----------------------------------- ------------------------------------.--.--- -------------------------------------------------------------------------------------------------------------------------------------------------- --- --------------- --------- I hereby 'e if that I have prepared this application and that the work will be done in accordance with San Joaquin County ordina 5, a--e-1'r, a,NS, 4nd rules and regulations of the San Joaquin Local Health District. [Signed)--- - ----- ----- ------ ------------------------ --------------------------- ---------------------- wrier and/or Contractor) By::-------------------------- - ---------------- --------------------------------------------- 'e'r & -en� MX - (Plot plan, showing size of lot,gocation. of system ' e ation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY I N ACCEPTED BY ........ ............. ....... DATE Y ------------ ............ APPLICATION ACCEPTED BY------------------- -- ----------- ----------------------------- DATE--- = �� - ----- --------------------- ----- ------ D BY REVIEWED ------- ---------------------------------------------------------------- BUILDING PERMIT ISSUED------ ------ -------------------------------------------4-------------------- ---------------7 DATE k _ -5, ----f 1A------ Alterations and/or recommendaf ions:--- 01 1�� ......... ----k--------- ZS ------------------C &A:6 ---------- ---------------------------------------------------------------------- ---------------------------------------- 41:1-ep+4--------- -------------I---------------I---------- ------------------------------------------------------------------------------------------------------------------I----------------------- --------------------------------------- ------------------------- --------- ------------------------------------- ---------------- -------------------- ------------------ -----------------------I------------------ ------------------------------------------------- ------------------ ------------- -------- ------------ ----------------- --------- ----------------------- --------------------------- ------------------------------- --------------------------------- -------------------------------------------- FINAL INSPECTION BY:-----a-iiprzbl�-� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy, California ES 9 REVISED 8.59 3M 3`60 F,P.00.