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FOR OFFICE USE: 'o ------- ... APPLICATION FOR SANITATION PERMIT ------------- (Complete in Duplicate) Permit No. ........ ------ ----------- -------------------------------------- ---------------------------------------- Date Issued ----- This Permit Expires I 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 compliant Ith County Ordinance No. 549. A), ---------------------------- JOB ADDRESS AND LOCATION- ------- I �a----'2 - ------------------------------------ Owner's Name-&OU�--�-- 7n- -- -- ------- ----- ----- -----------------r-- ---------------------- Phone Address- ....... y--------- -----------------------,--/--- Contractor's Name_ -------------------------------------------------------------- ---- j Installation will serve: Residence,�---I artment House ❑ Commercial E] Trailer Court [:] Motel 0 Other ----------------- Number-of living units:, id--- Number of bedrooms -------- Number of baths -Lot size ... ------ Water Supply:'. Public system El Community system [I Private 1��epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel F Clay D Adobe E] Hardpan 0 ] Sandy Loam pB`Clay Loam [] Previous Application Made: (If yes,date-----------------__) No 0 New Construction: Yes El No E] FHA/VA-. Yes E] No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is .available within-200 feet.) So Tan : Distance from nearest well_________________Distance from foundation--------------------Material--------- -------------------------------------- No. of compartments-------------------------.Size-----•----------------------:---Liquid deplfh--------------------------Capacity----------------------- 6C Tic" —I Di osal ia4d: Distance from nearest well Distance from foundation__-/57----Distance to nearest lot line___-------- --------- Number of lines -------------------Length of each .......Width of french.A,41-rf---;i--------- czv ---------------------9e-------------- V Type of filter material!' Depth of filter I ---------Total length Seepage Pit: Distance to nearest well----- -----------------Distance from foundation____-____________-Distance to nearest lot line_________-__--._-- Fi Number of p;fs.---------------------Lining material------------- ---------Size: Diameter----------------- .---.Deptk--------------------------------- -om nearest well-----------------Distance from foundation--------------------Lining material--------------------------------------- Cesspool: Distance from Liquid Capacity----------------------------gals. 0 Size: Diameter------------ -------------------------Depth--------------------------------------------- ------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.--____-_---______-__________-______----_. 0 1) nDistance to nearest lot line------------------- ----------------------- --------------I------------------------------------------------------- Remodeling and/or repairing (describe:_ ------------------------I-------------------------------------------------------- ----- --- --------- --- - ---------- -T7��------------------------------------------------- .-7 ---------------------------------------7----------------------------------- ---------- --- . -- --------- --- ----------------------------------------------------------------I------------------—-------------- --------------------------------------------------------------------------- ------ ----------------------------------------------------- ------------------------------------------------------ -- ----------------------------------------------------------------------------------- -------- ---------------- I hereby certify that I have prepared This application and that the work will be done in accordance with San Joaquin County ordinances. IS laws, and rules acid regulations of-the San Joaquin Local Health District. (9&ewwrrdJ/-er Contractor) (Signed)--�-5- - --------- - - ------ 7----AAi----------------------------------------- By:-------------------------- ------------------------------------------ ------------------- --- - ------------M--- - ---------(Title)-- # )-- ------------------------- ------- -4 (Plotplan. showing size of lot, location.of system in relation f/ells, building etc., can be placed on reverse side). FORD RTMENT USE ONLY -zo APPLICATION ACCEPTED BY DATE-------- ----- 00I ---------- REVIEWEDBY------------------------- -------------------------------------------------------------------------------------------- DATE---------------------------------- ----- BUILDINGPERMIT ISSUED--------------------------------------------:---------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:------ ------ -------------------------------------------------------------------------------------------------------- --------------------------------------- ------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------I------------- - ----------•---------------•- ----------- --- --- ---------- ---- ''l- mac - oy` ----- FINAL INSPECTION. --1:A----------- ----------- ------- Date----- -------------- N SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9L p9VISED 8-69 3M 3-'63 F.P.Q0. 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