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FOR OFFICE USE: -- 1111- -----=111 1----1111-- ---------------------- --- ---------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------------------------------------------------- (Complete in Duplicate) � S� --. This Permit Expires 1 Year From Date Issued Date issued ._______� _ _..___ -------------------- 1-------------------------------- 1317-D f O ..S'/ 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. S49. 1:v JOB ADDRESS AND OCAT(COIN.yleoxel_.410 -_ ___ ----� ,--1 - -- --' ��-------+ Owner's Nam =�'�' �Lc ----- - !'--- -`.------ ° Phone ------------------- Address Q t "x' - -------- :_ - �'- - -- •--•------------------------------------- -------• Contractor's Name---- - g"'a"`r'!=` .. `• � �__ ''147 Phone -1111--------••----------- Installation will serve: Residence ❑ Apartment House ❑ Commercial [f Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms `- Number of baths _ Lot sizemak' __ . -- --------------- Water Supply: Public system ❑ Community system ❑ PrivateJ�Depth to.Water Table ------ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe.[-] Hardpan ❑ Previous Application Made: (If yes,date--------_----------) No ❑ New Construction: Yes ❑ No ❑ rHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) 1 Septic Tank: Distance from nearest well-----------------Distance from foundation---------.---------.Materiai------------------------_-..----_--_.-_.--.-__-_. ❑ No. of compartments---------------------r---Size--------------------------- ---Liquid d�Pth---------------------- ---Capacity--•--•----------------- Disposal ield: Distance from nearest well.-_6�'_._.._.Distance from foundation_ ,/_:_:-Z,,/C -::Distance to nearest lo` line_...V_r------- $ Number of lines----------I--____--- --------------Length of each line4__�___ e----.-�__-_-Width`of trench__Z_-_-;-.----_-_-_-_-__._-__ . �� Type of filter material-_ /_• r-_______Depth of filter material--------,�9___.....Total length___._____K0?7__________________ Seepe,g�-Rrt; Disfance-to-iear-est well-----./47A`_'._-Distance from foundation__—t-0----._._.Dtance tonearest lot -a-_ /�. d6� f Number of Lining material_----- .. _c--Size: 3-47/10-, Depth_.-- --- -'r-------------- _�ferial'� -- ------ - -- -. i r.. V Cesspool: Distance from nearest well.................Distance from foundation _.__�__,'':___.Lining,material-------------------------- F1 Size: Dianneter--------------------------------------Depth----------------------------- ._-- -_- _--------Liquid'CapacitY -- gals. Privy: Distance from nearest well---------------------------------=---------------Distance from nearest' building---------------------------------------------- ❑ Distance to nearest lot line.,.____-------------_ - `` q a�-.-_-_---.-_---_---.-------------------------------------------------------------- =----- J Remodeling and/or repairing (describe)=----------- - �. ------------ -•----------------1111------------------------------------------------ •----------------------- -------------------------------------- _----------- --------------------------------------------- --------- ----- ----------------------------------1111------------------------1111-- --------------------•---------------------•-••--------------- ----------------•----------------- -----------•--------------------- --- ------ - v I hereby certify that I have prepared this ap�licatio and +hat +he work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San-Joaquin Local Health District. a` ___-- '--------------------------------------------- } nd or Contractor (signed}.1111--1111----- ------------1111-- -- - - --- 1111-- --- -----------111111 11---- --1111-� / ) ��-- BY--------- - - ' + 2, --(Title)--------- ------------------- ---------- l - -------- (Plot plan, showing size of lot, location o sys em in. la+ion to wells, buildings, etc., can be placed on reverse side). , FOR DEPARTMENT USE ONLY -- ` APPLICATION ACCEPTED BY-------- ----------------------------------- ---------------------------------------- DATE------ - -( - '------ ------- REVIEWEDBY---- - ------------------------------------------------------------------------------------ --------------------------------- DATE------ ------------------------------------ ---------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------'---------------- Alterati�ons�and/or nd/or recommen-.•=-tijns:-YF-'-----------------�--y---- --------------------- '.------------------------------------------------------------------- ••----------_-------------------- ------------ r-J-.4ee.-� __..L�_q ___-.__.__ 1__________________________________________________ ----------------------------------------------------------------_.-...-____.__....-_-._-..___---__--_.-_-_.-----_-----______-_--_-_-______-_-_-_-_----._--_-.-...-_-___----.-_-__---_..-.-_-_---_--_---_-____-_-__-_-----_. ---------------------------------- - ---------------------------------------------- - ----------------------------------------------------------------------------------------------------------------------------- ----------------- . t FINAL INSPECTION BY:.------ -iF_�`-1 --------------------------------- ---------- Date--- '�� '�=��`------- -- ------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street: Stockton,California Lodi,California Manteca,California Tracy,California - ES 9 REVISED 9-S9 3M 3-'63 F.R.CV. +