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FOR OFFICE USE: 9llaru 7��y5(a -------------------------------------------------------- -------------------------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. ....-___� ...� i -------------------------- ------------------------------ (Complete in Duplicate) Date Issued _______--"/� -..H-a_-- --------------------------------------------------------- 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. JOB ADDRESS AND LOCATION �� ----- �// Owner's Name------------ ---��,L�_r_�---- --------------------------------------------------- Phone__I�-19__ Address------------------------ ° rl a --------5-t---t'Yh .------• --------------------------------- •---•-------------------------------------------------••--•---------- Contractor's Name--------------_-; `'`�' ---- -FT--------------------•----------------------•------------------------------------------- Phone-----------------.-_--••--------- Installa#ion will serve:. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .----- Number of bedrooms _�A_• Number of baths __!•-__ Lot size ..........5, _ .____l.r -_Q-__________ 17 Water Supply: Public system '0 Community system ❑ Private ❑ Depth to Water Table ___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeM Hardpan ❑ Previous Application Made: (If yes,date19-J_____) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:>#I/579-0 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se is Ta k: ,. Distance from nearest well_________________Distance from foundation--------.-----------Material ________._____..--_-_-_________________________- No. of compartments-----------------------_Size-----------------------------...Liquid depth----------- --------.Capacity------------•---•- is Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line------_____-_ Number of lines-----------------------------------Length of each line------------------------------Width of french-----------------------------.----_- Type of filter material_________________________Depth of filter material ______ Total length . / 1 -----------j .____ ---------------------------------� ��__/�?�h_ ___ Seepage Pit Distance to nearest well-� =_Distance fro fou ation__!`� h _.___!�_- Distanfe to nearest lot line_r____. Ln r Q9- Number of pits--------(___--_------Lining material--- r_ GSize: Diameter____ ---_____--Depth----159— - ------------------ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------.----------------------------__ ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity---------------...----------gals. Privy: Distance from nearest well-------------------------------------------_-----Distance from nearest building_____...___________-_________.____.---.-. ❑ Distance to nearest lot line----------------------------------------------- --------------------------------------------------...----------------------------------------- Remodeling and/or repairing (describe):-------- ��`_" h ` ------------------------------------------------------ ------------------------------------•---------------------------------------------•- --------------------------------------------------------------•------------------•-----------------•-------------------------------------- ----------------------------------------- ......------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby ceW,: epared this application and that the work will be done in accordance with San Joaquin County ordinances, St # nd reg a#ions of a San*Joa uin cal Health District. (signed} ------------------------------------------------------------(Owner and/or Contractor) 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 z -------------------•----------------------- DATE----------- }} f REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------- ---------•-•----------------------------------------------•------------ DATE--------------------------------------------------•------ -- Alterationsand/or recommendations----------------------- ------------------------ -----------•---•----------------•--•-----------•-----------•------------------------------------------------•--- ------------------------------------- -------------------------------------------------------------•----------------•----------------•---------------•--•----------------•------------------------ •------------------------- -----•----------------•------ ----------------•--------•---------------------------------------------------- -------------------------------------- --------------------------------------- ------ - ------ ----- FINAL INSPECTION BYDate---------------- ' f: <7------------------•-----•---- SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California { E5-9 REVISED e-59 F,F.C7.SM 6.67 I