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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .C? .O 1 .- (Complete in Duplicate) ° -- Date Issued ___________ ___________ This Permit Expires I Year From Date Issued )44� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, This�ap.plicattinn is made in compliance with County Ordinance No. 549. -- _ - ---r- - l-- -- ----- -- �r�c`-4a. --- -- /' - 1--- .I -1 Z_- ! JOB ADDRES , ND LLOCATION -04+-! --b --- ---- -Owner'sN -- ---- --- --- --- ---- - ---- ---- j ----------------- --------- Phone---- Addressx------ 77-----------------•---------- - ----------------------------- Ph __-•---•-------------. --------- Contractor's Name ---- i Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I Number of living units--- --- Number of bedroom— Number f baths _ Lot size .__-._ >--r ---------------------- Water Supply: Public:system E] Community system [:] Private Depth t Water Table -------- ft. : �( Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam,❑ Clay ❑ Adobe❑ 'Hardpan ❑ • I� Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FNA/VA: Yes❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: € (No septic tank or cesspool permitted if public sewer is available within 200 fee}) t_ Sep#ic ank: Distance from nearest well------ Distance from foundation------- O-k±___.Material_____ _ __ ___ _________ -------------- t rr No. of compartments____a2________________Size __�_ /e[_ -j,ah_ffjLiquia depth---t,.�_._ ----------------Capacity#_/_Z6.et Dispos ield: Distance from nearest well ____-54_ .-_Distance from foundation-_-0- Distance to nearest lot line�°:f--------- Number of lines---------------1---------------------Length of each line--y. � -_-----!____'.Width of trench--2---" ?----------_----------- it � Seepage Pit: Disaoeftoenearestlwlell___ _ _________Dstancef frlotmrfoundation ,_...._..it mate Total length____. �--------------------.__.__-_ } __`'Distance to nearest lot line_________________ Number of its Linin material-----------_-_------_----Size: Diameter-----------------------Depth-----.•--------------------__-_-- p --ea ell- g --- -------------------=---------� ❑ p : g dation__--___-_'-_��_____.Linin material. _ Cesspool: Size: D amleter nearest well------------- --Depth Distance from 'four-----`-:-------- 1; ----Liquid Capacity-----------------------------gals Privy: Distancefrom nearest Weil__ __--.-----------------------------------------Disfance from- earest building________ __.-____,_____________.-_-_ - ❑ Distance to nearest.lot line____________________ �'"-`d ---� Remodeling9?r i S"jdescribe):----------------------------------------------- --------------------r---:--- -------------------•--------------- ---------------------------------------- -------------------- -------- ------- - = _ - _ _-______ z - . : ____ ---- ________ _ _ ______________________________________I___-_. I hereby er 'fy that I have prepared this application and that the work will be olone'in accordance with San Joaquin County ordinances, tate ws, and rules regulations of the San Joaquin Local Health District. (Signed} _ ----9---------` ;---------------- ------ --- ------------------------------ nd/or Contractor) - -:----`-----------------------------------------------------(Title)----------------------------------------- (Plot.plan,- owing.size.of..lo},,location of cyst in-relation to wells, buildings, etc.,-.can,be placed_on reverse side)._ - S ri FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY_. ---------------- -------------------------------------- DATE--- --/3---e-t--------------------------------- REVIEWED BY-------------------------------------------------------------------------------- ------ DATE-----. ------------------------------------------------------ BUILDING -----------=--------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------- ------------------------- DATE.--------------------------------------------------- Alterationsand/or recommendations--------------------- ---------°----------------------------------------------•-------------.---------•--------------- •-------------------- I ----------------- --------------- ---------------------- ----------------------------------------------------------------------------------------------•- ------------------------------------------------------ ---------- FINAL INSPECTION BY: r"= Date ---- --� ��° SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 5 REVISED B-59 3M 3-163 F.p.Ca. E