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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT Permit No. ------ ----------- --------------------------------------- (Complete in Duplicate) Date Issued --------------------._.- ---------.._..._._...-----..., _ This Permit Expires 1 Year From Date Issued i 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....-.-/ice .._. 7. ------------ -------------------------------------------- Name---- 0--�/�-----0" ----------- ----------------------------------------- Address ------------ - ------- Phone Address-----•------------------------- r-4 - ------ - ........ ---- ----••. Contractor's Name--------------------- -------- --------------------=-----.:.--------------------••---------------- ------ Phone------------------------ Installation will serve: Residence El Apartment House ❑ ` Commercial ❑ •Trailer Court ❑ Motel ❑ Other LK/ Number of living units: +"Y N r of bedrooms ..- Number of baths__ Lot size __ ___142rs�..l'---------"`----------- Water Supply: Public system Community system ❑ Private epth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe gj_>3rdpan ❑ a Previous Application Made: (If yes,date..---...,,-...._._.....) No [ "'New Construction: YesNo ❑ FHA/VA: Yes ❑ No Q " i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest w ll-----------------Distance from ,foundation__L..S-----------Ma- teri !__.___ _...1' ..�----- � . � � , No. of compartments-------- - -- ------- ___. ., -Liquid depth----.- �,z.--------_Capacity... _-----. Size -. 1 Dispgs eld: Distance from nearest )'`ell-:' �_____Distance from foundation..._--...---Distance to nearest loft line... ........... [d� s Number of lines.......... ..... . Af Length of each line___: --------Width of trench qP-- A Type of filter material._..j1x, _ .1 'epth of filter ma terial_...`i_...._-____Total length__. ................................ Seepage Pit:,, Distance to.nearest well......................Distance from foundation-------------------Distance to nearest lot line_--.___.____-_-- ❑ �".j Number of pits----------------------Lining material-----------------------Size; Diameter-------------------.---Depth--------------------------------- �1 Cesspool: Distance from nearest well ................Distance from foundation--------------------Lining material-.._______---..-------------.....__ tsb ` El Size: Diameter-----------------.-------- ---------.Depth-----------------------=----- ------ -------------Uquicl Capacity----------------------------gals. Q Privy: Distance from nearest well._._-----------_..................._._._._-...Distance from nearest building--------------------------------- ........ '1, 4 ❑ Distance to nearest lot line---------------------------------------------------------------------------------------- --------- ------------------------------------------ Remodeling and/or repairing {describe):_...-> � - ------ Jf ------.xy_--0.o •----r-t'-------�Alz -------- ----------------•----------------------------------•--- ---•--------------------------------------------------•- ---------------------------------------------- _7 ---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State law and rule Z and regulations of the San Joaquin Local Health District. t.``N."F ,� f r (Signed)-------------- I --------------------- - --------------------------------- --- ----------- (Owner and/or Contractors ------------(Title) t.v✓fI---- -------------------------- (Plot ------- -- ---•----------(Plot plan, showing siz lot, location of system in relation to wells, buildings, etc.,'can,be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYIIIQ - -----------------------------------�...DA7F ` r - --- - --------------- REVIEWEDBY. - - �` ----- DATE-------- ;------------------------------------------------ BUILDING PERMIT ISSUED----== � -' DATE------------------------------------------------------------- - and/or recommendations:------- ---------------------------------------------- -�'------------------------------------ --------•--- ---------•--------------------------------------- Y i , 1 kr - z n FINAL INSPECTION BY:--- - --------------------------- Date.......0-)-J-57.0----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha=etlon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street } Stockton,California Lodi,California Manteca,California Tracy,California F.F.CC.