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t-UN UFFJCE USE: ------------------:---- ------------------------------ ----------------------------- ----------- -----------------=----_____________________________ ___________ ______________ APPLICATION FOR SANITATION PERMIT Permit No. _..,.................... {Complete in Duplicate) t ------- Expires --- --��- ----------- -��----�--- This Permit „ 1 Year From Date issued - --� Date Issued Applica+ion is hereby made to the San Joaquin Local Health.District for a permit'to construe and instal! the work herein d scribed, r This application is made in compliance with County Ordina ce No. 549. � /� JOB ADDRESS A CATIO Owrie•r's Name____. - - ------ y-- -- Phone Address----------•- ai ----- - - �-I7--0-- ---- -- ------ '--3------^---------------- . Contractor's Name,____'.___ : _- �-_ hone------- - Installation will serve: Residence &-_'*Apartment House ❑ Commercial Trailer Court ! - r ❑ ❑ Motel Other � Number of living units: ':.` _ Number of bedrooms . 5p Number of baths _ _- Lot size ____- ____ -` _ E.1..c a Water Supply: Public system [❑ Communitysystem y ❑ Private ❑ Depth to Water Table Character of soil to a 'depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay_ Loam Clay ❑ Adobe ❑ Hardpan F Previous Application Made: llf yes,dote:_=_._ , ---=� 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 neares rwelt" �____Distance from foundation """""'s' ' T=" ° _-__Material_ __._ „" ------ ` .. ------Capacity----------------------- ❑ZR No. of compartments----- ---�---- Size---------- ---------------------Liquid dep�h--------- ryi I k �. Dispo : distance from nearest well_--,,, _--_Distance from founda+ion______/0__ _.__Qisfance to nearest lot line___ r____. Number of lines___ _________ 1-' y - Length of each line______ Q_� -_----- 1�lidth of trench_____ __ ___ ------------------- Type of filter material t Depth, of filter material_-_____ -- _ Total I T t I ength-__---- _ Seepage Pit: Distance to nearest.well_._�•_-------------- Distance from foundation______________ _____Distance to nearest lot line-______-______--- .:�.;,w.«�Number of pi#s '.�....."---- ning.material------------- g-------Size: Diameter. - ---.Depth Cesspool: Distance from nearest wel! h_Distance from -foundation ,-----------------Lining material__-_______ ------------ AI Priv❑ Sze: Qiameter.__ = =' Depth---------------- - Liquid Capacity- - -- { gals. ---------------- Y: .Distance from nearest well____________________________ � -. ,Distance from nearest building--------------------------- _______ ElDistance to nearest lot line-____-__ -- --- ------------------------------- Remodeling and/or repairing (describe)________________________ ------------------------ -------------- -, r 1 � ,. --------------- - ------ __________--------------. _-____«._: ______________.____-________-____________________.___________--_-______-____________-__._____._________-_________.-.________.________-________.__-_-.__ ---- -___-_.____yam~Y_ m _ 0, I hereby cerfify 4h.a+ I have prepared this application and that the work will be done in accordance with San Joaquin County, ordinances, State s,and rules an regulations of n Joaquin Lo4,_V_alth District. (Signed)------------ - - -- -----I wn ntd/or Contractor) BY= -•" , �_-- -- ---- (Title------- - _ _ _ y _ .- r - (Plot plan;showing size of-IotTlocati0 of s s+em in relation to Ils, buildings,—.tr., an be placed o everse side). (, FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY -0---- --------------------- ---- DATE__ _ CP"--(_ REVIEWED BY ----_k i. DATE -------- ----- -BUILDING PERMIT ISSUED.----------- ----- - --------------------- --- --------_------------- DATE- - - - ------}------------ Alterations and/or recommendations:-____-_---_____________ . 5 -----•---------- ____-____________________i--_______.- t- k t ---------- ---------------------------------------------------------- -------------------------- •---------------------- FINAL INSPECTION BY: ft Date-- 1r-3 ---- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1607 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California £S Si REVISED a-59 3M 3-•63 F.A.CO. i � J r�