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ly. FOR OFFICE USE: : - ------------- ' ----- zap" ..] y- _ _-__--------- _ _ APPLICATION FOR SANITATION PERMIT Permit N0. ../..�_ p" .. .� -----'--------'-- - ---------'---'---'-------- -- (Comple+eai�Duplica+e) -' - s Date Issued --------_---------__..........____-___--.-__._______.___ This Permit Expires 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. 5549, JOB ADDRESS LO AT10N_' II`' C e-:------------- ---------------------- •-------•------------------------------------------------------ Owner's Name :. :. .. Phone ------------- ---------------------- - -- -..- ' -2� ' Address = �.. :. 1, .. .... ------------- -------- - i t. Contlractor:'s Name------ r -------------------- --- Phone,%_-•--------_---- Installation will serve: Residence [t3•---ikpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ -Other ❑ -.4 Number of living units: --,I-_Number of bedrooms .-- Number of baths i------ Lot size _ - --- - ------------------------------------- Water Supply: Public system. Community system ❑ Private ❑ Depth to Water Table P f#. ; Character of soil to a aep+h of 3 feet:' Sand ❑ Gravel ❑ Sand -Loam ❑ Clay Loam El Clay El Adobe �ardpan ❑ brevious Application Made: (if yes,date:,.._...............I No New Construction: Yes :Ey,-1To_❑ FHA/VA: Yes [1' No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic h: Distance from nearest.wel___°' ___..__Distance from foundation_`___________-Mat`rlal____f------------------------------------------- No. `Q `---'�'�_l________________ No. of.compartments___ �._.-____....__Size____4-_x' ' 9.__------Liquid depth_-�-------__.--______Capacity__.-kZ!A- Disposal Held: lrear, st well - - ---- Dafrom foundation-_40 c } nearest lot line'r---------- ----- -Numbeof lineSj , - - ---- ength of each line__ P-40--_r _________._ Width oftrench ------------ ----- offlter -_____..To ___ __ __________________________TYPe.of.filter materia .... -- De Depth talfen _�d - Seepage Pit.- Distance to nearest well_._____------------Distance fromfoundationl!?Z-----------D' t�' to nearest lot line': _.___._ Number of pits----' ---------------Llning material....... -------...Size: Diameter......----___-- --------Depth-- 3��------------------ 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):-------------------------------- --------------------------------------------------------------: ---------------------•-------------------------------• 4 ---------------•----•--..-.,---•------------------------------------'--------•----•--------------•----------------------------------- ---------•:---------------'-----------------------------•--------------- ---------------- ---------------------------------------------------- ----- ----------------------- ---------------------------I -----_------------------------------------------------------------- ' j A-s :�� r_ ee_________________ ___.___________...__.. A "•:�!•hereby certify that Ijand re his plication and that the work will bA6ne in accordance with San Joaquin Count O iAances, State laws, ande ati sof th6 San Joa�Local Health'District. (Signed)------------------------;---.---- ----- ---------- --- ---------------------------------------------------------------•-------------------(Owner and/or Contractor) By:----------------------------- -- --------------- ' -------------------------------------------- ------------(Title)--------------------------------------- - ---- (Plot plan,-showing-size of Iof.system in'relation to-wells, buildings,,etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -_ ,_�'� ----------- ----- ---- ` APPLICATION ACCtEl;TED BY--'- -- - -------------------- DATE ------------'--- REVIEWED BY t' DATE-------•------------ BUILDING PERMIT ISSUED--------- ----- - i - -------------------- tDATE---------------•-----'-------------- _ _ :. ,. Alterations and/or recommendations-----------------i------- ' - ----------------------=- ----' ' - ---------------- -:-----------' FINALINSPECTION .BY----- -------------------------- ----- -- ------------=-------- _ Date-------------^µ--------- '------------------...:.----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California t Lodi,California Manteca,California Tracy,C«iiforn`a • a. ES 9 Fr£VISE6 9.59 3M 3-'63 F.P.CC.