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APPLICATION FOR 'SANITATION PERMIT Permit No. (Complete in Duplicated Date issued �, o- This Permit Expires 1'-Year From Date Issued.. Application i 'hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. s This application is made in compliance'with County Ordinance No. 549. rYl } JOB ADDRESS AND CATION 7'`"0 'v '+,-----------------2 1 ------ ------------------- Phone- -------------•---••---- Owner's Name------------------- -------•-- ---•----.-.-----•-----•--- ---------•------------ ----------- - /L. 17:1-1 OF-,� 1 � � --------- ----- -------------------------•-- t . Address----- 11----- `1l — � -- -----'--• -- -- --- Phone............--------_----------- -------------------------------Name------=----------------= _.. -------- -- -- � -- ------------ - --•--••-•------- Commercial Trailer Court ❑ Motel ❑ Other 11 Installation will serve: ,Residence', - Apartment ❑ ❑ .I -%;;— ,Number of baths _1--- Lot size -----------Zq-'-`��-:.�I-s----------------- Number of living units: ___ Number of bedrooms �____ Water Supply: Public system [I Community system El Private Depth to Water Table -------- ft. Character of soil to a depth of 3 fee I- Sand ❑ Gravel El .Sandy Loam ❑ Clay Loam [IClay ❑ Adobo'151, Hardpan ❑ Previous Application Made: Yes'D ! No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ M o V nJ TYPE OF INSTALLATION AND SPECIFICATIONS: fitted if public sewer isavailable within 200 feet.( (No septic tank or cesspool permitted m p k Se t Tank: istance from nearest well--______________Distance from foundation_____________'__._.Materia_________________________..---___- -- of com artments------ ------------ -----Size_Sizel---------------------- -----Liquid depth-------------- -----------Capacity pl, -e Disposal Field: Distance from nearest well - Distance from foundation________�_V_..._.Distance to nearest lot line_____- ( V Number of lines-----------------I----------.------Length of each line------------'?_v-{____:_.Width of french-------- - -- ------ -- f I - ' Type of filter material'___ '"-'---Depfih of filter material____ - ��----�---Total length---.____.______------•-�-----•--=- p i! [ lineN Se pa Pit: Distance to nearest well----------___________Distance from foundation___-_______-_______.Distance to nearest lot .._____.______.._ 0 p I - 9 al---------- -- Size: Diameter Depth ; Cesspool: li: Distance from nearest well_____'_______---Dista3 Number of its__'______ ___________Linin maters nce from foundation--------------= ---Lining material-_----------------------------------- p Liquid Capacity----------------------------gals, ❑ Size: Diameter---E-------- ------------------------Depth--------------------- ------- ----- ----------- a p Y i , _____ ____________--.__._____----. Privy: Distance from nearest well________-----------------r-� ------------- - - Distance from nearest building_____ ,. -- Distance to-nearest.lot line------------------------ - t -------- ----------•-------•-----------------------------------•---- Remodeling and/or repairing {describe):___________________________________-----------------._ _ 1 ----------- ----- ------------- ------ ------------ ----------L--------_ ------------ -- 1�. Q I hereby certify t 4t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,!:State laws, and rul and regulations of the San Joaquin Local Health District. r (Signed)- 1 ---------- .(Owner and/or Contractor) t � o � I .O d/ ,�--------- - 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------- ---- --•�•-------------- ---------- DATE l a ItDATE--------------------- REVIEREVIEWED" --------------------- WED BY = DATE------------------------------------------------------------ BUILDINGIPERMIT ISSUED------------------------------- I Alterations` d/or.recommen ations------------------------------- ------------------------ ---- ---------------------------------- - -------------- ---•- 1 --------------------------- ---- --------------- -- -------- 1 . FINAL INSPECTION BY:..—... ------- Date ' SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 3 130 South American Street Tracy, California Stockton, California Lodi, California Manteca, California y .d 55.9-2M Revised 0-'59 F,P.Co