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FOR OFFIC U E: --- 1-x_3 ----------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ___ ..... . ------------------------------------------------------- (Complete in Duplicate) - -------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ______...- .6 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. JOB ADDRESS AND LOCATION -- -------------------------•-------------------------••-----------------.. ---------------••-- --------- ------- JOB Name----- � �--------------- -----------------•----------------------------------------------------------------- Phone ----••----------•-------•-----•-- Address.............. ---------------------------------- ------------------------------------------------------- -------------------------------- --.....----------•--••----------•------------- Contractor's Name------ Go -- '-- ------------•--•---------- Phone ............................. t Installation will serve: Residence 0' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of livin units: ___1___ Number of bedrooms _3___ Number of baths _1_..-. Lot size ___/ z- = — ------------- ----------------------- Address LnaraGTF7r 07 ZoV91 IV a yarn, v, 4 ,co,. -ra,� IJ v�.,,v� �, ........, _.._.. __-.. -. city fes°>�1�-�„ Previous Application Made: (If yes,date----------- _-------- 1 No 0 New Construction: Yes 0' 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 ------------------ --.--__-________.____.____-_--. 6 / No. of compartments ---------• --------------- Size ------•-----------------•------- Liquid depth---------------- --------- Capacity ----------------------- Disposal Field- , Distance from nearest well ----------------- Distance from foundation ----------------- ...Distance to nearest lot line ----------------- ❑ �f Number of lines----------------------------------- Length of each line ------------------------------ Width of french .----.--------: ----------.--------- Type of filter material ------------------------- Depth of filter material ----------------------- Total length --------------------------------------- See pa a Pit: Distance to nearest well _____ Distance from fpundafion_f/®------------- Distance to nearest lot line ___--.__.. Number of pits ------ --------------- LiningSize: Diameter--?:�--�------------ Dept h___'________...____..__ Cesspool: Distance from nearest well ------------ _____Distance from foundation -------------------- Lining material ___.________--..--_________________-_ ❑ Size: Diameter -------------------------------------- Depth -------------------•------------- ------------------ Liquid Capacity --------------•-••---•------gals. Privy: Distance from nearest well ------------------------------------------------- from nearest building ----------------------------------------- . ❑ Distance to nearest lot line ---------------------------------- ----------------------------------- ------------•-------------------------------------------------------- Remodelingand/or repairing (describe):----------------- --------------- ----------------------------------------------------•--------------------•---••-------•-------------------------------- --------•------------------------------------------------------------------------------•------------------------------------•-----------------•--------• ------•-------•------------------•-------------- ------•-----------------------------------------------------------------------•--------------------------•----------------•-•------------------------------------- ---------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and rXgulaons of the San Joaquin Local Health District. (Signed) - ----------------------------------- -------------------------(Owner and/or Contractorl By:.------------------------------------------•----------------------------------------- (Title) - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____ -____________________{.---j REVIEWEDBY-------------------------------------------------------- 41�[ BUILDING PERMIT ISSUED ------------------------------------------ DATE/ tl� ----------------------------------------- DATE------�_A,------------- - ---------------------------------• DATE ------------------------------------------------------------- Alterationsand/or recommendations:------------------------------- ----------------------------•-•-------------------•-----------••----------•---------------------------------------------•------ - --� - ------------------------------•-----------•--------------------•-------------------------- •----------- I.,-•---------------. - ----------- - - - f !----------------------------------------------------- --------------------- FINAL INSPECTION BY: ---------------------- Date -----a �f �� -------------------------------•----------- SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton, California Lodi, California Manteca, California Tracy, California E6-9 REVie ED 9.59 F.F.CO. 2M 6.60