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FOR OFFICE USE: ---------------------- ---------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...... ------------- --- ---------------------------- ---------- (Complete in Duplicate) Date Issued Z/_ 4 _may - -------------------------------------- ------- 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 Ordinance No. 549. j Sr44�+�7` / pJ� V A �4� u. JOB ADDRESS A D LOC ION. " ------- Na Owners Name �r?�11 --- ---- --- �' --------- -----------------�'-i----------------------- Address --------------- _ Phone. ? Address----------- --- -=�..... -- .....1 .31�"..---- ------- -- -------------------- ----------------.._..--------- ----- -------....... Contractor's Name--------------------- - -- ------ ------ - Phone --------r.. -------------- Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ , Number of living units: ----- Number of bedrooms .--- ._ Number f baths __- -_ Lot size --------_��- - -------_ Water Supply: Public:system E] Community system Private Depth t Water Table,.- -_ ft. C j} Characfer of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ ! ardpan ❑ Previous Application Made: (If yes,date-------------- --) No ❑ New Construction: Yes ❑ Noe El FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t [ a septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic ank: Distance from nearest well --_4_"Dise from f and tion"--""" _Q-------.Mat rial_.""" ------------------------------------- 'an P ��// } No, of compartments...-" . Size .-�i- ___,� ! Liquid depth_---_ -._- ------.Capacity..�er_ Dispos Field: Distance from nearest well_.5A.-- `7 Di once from foundation__----AD------Distance to nearest lot 1`e,_;-,--.----- Number of lines-------- .__-"yy___ _ Length of;each line-lA&2--"+r; _".Width of trench.____-�"_."--�-------------- i Type of filter material--" Depth of filter,material-"""._"/"q"_ -"_-"Total. length_"_-"""-" _"-""-""--_-_"---- ' ---Dth .- I Seepage Pit: Distance to nearest well------.-_--- Distance from foundation--------------------Distance to nearest lot line----------------- I ! l❑ Number of pits----------------------Lining material------ -._-".ASize: Diameter---------------_-----.Depth_.----.-------------------------- yCesspool: Distance from nearest well-----------------Distance from`foundation------------------.Lining material---------------- -------------------- Size: Diameter--------------------- ----------�_`[__---Li- Liquid . acit . r❑ -----------------Depth- ----- - ----=-----�`�-� y q r p Y- - -- - -- -----"9als.1 i Privy: Distance from,nearest well------------------ ------------------"__------_.-Distance from nearest'buiiding-------------------------------- : ❑ Distance to nearest lot line--------------------------- t '�- - ------------------------------------------------ ------------------------------------------------ --- Remodeling and/or repairing (describe): ------- ----- - -- ---•-- ------^ -------c--------- . ---------"---------- �- {.. ------- ------- - --------------------- ----------- 01 -= -------------------------------------------------------------r`---------=---------------------------------------------- ------------" / I Irhe�re_bycerci y that I ave prepared this application and that the work ;4F be dorse`in-accordance with-S'an Joaquin County t iT ord finances, State laws, and rules and regulations of the San Joaquin Local Health District. ( r (Signed)--------------------------------------------------------------------------------------------------------------------------------------- -------------------------(Owner and/or Contractor) BY:------------------------------------------------------------------------------------------------------------------------------------{Title)--- ----------------------- ---------------- hPlot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)./ FOR DEPARTMENT USE ONLY r• , ' 1 `` APPLICATION ACCEPTED BY--- -- ------------ ------- - -------------------------------------------------------- DACE- = " " -`-- ----------------------------- ' REVIEWED BY-------------------------------------------- --------------------------------------------------------------- --------•- DATE------------------------------------------------------------- DATEPERMIT ISSUED---------------------------------------------------- ------------------------------------- -----•--- DATE t ---------------- I Alterations and/or recommendations: ----------------------- --------- - .--- -----------------"-----------------------------------•--------------"-----.--...------------------------------------- ------------------------------•----------------------------------•----------------------------- ------ al ---------- ----------------=----------------------------- ------------------------------------------------------------1_-•--------------------------.-...-------•------------------------------------------------ t ------------------------- ----------------------- ------- ------------------------------ ---- - -------------------------•------------------------- -------- ----------------------------------------------------- --- t. _ F- - ar- _ .. .. . , - r -------------------------------------- ... ---------------------------------- -------------------------------•-----------------. ------------------------- ---------- ----------------------------------------- ITI 4'h 1 FINAL INSPECTION 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 ManteCar California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD. 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