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O- FOR OFFICE,USE /,-`-0------ i APPLICATION FOR SANITATION PERMIT Permit No. izz�J_l.J�L --------------------------------------- f (Complete in Duplicate) S � Date Issued -------------- ------- 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 A -- ND LO ATION -9Y�7E ----- d� ------------------------------------------------------ I Owner's Name.--- --- ---• Phone r Address------------------ - ----------------------------------------------------------------••-------- I k Contractor's Name..± ---- ------------ Phone----------------------------------- `� 7� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-.j.. Number of bedrooms -_3__ Number of baths .2— Lot size .... t- .... ------------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table Xft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa y Loam ❑ Clay Loam ❑ Clay ❑ Adobe�]�dpan ❑ Previous Application Made: (If yes,date----- -.-) No ew Construction: Yes ❑ No4�'FHANA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No se ank or cesspool permitted if public sewer is available within 200 feet. t Sep c Tank- Distance from nearest well- ................Distance from foundation----------------- Material__---...-____.... _-.....-..---.. No. of compartments---------- - -------------Size---------------------------- ---Liquid depth------------------------- Capacity----------------------- Disposa ie Distance from nearest well...-------------Distance from foundation--------------------Distance to nearest lot line-------.--------- Number of lines-----------------------------------Length of each line—---------------------------Width of trench-------------,--------------------- Type of filter material-------------------------Depth of filter material----- Total length-----------------_----------------- -� S r ---See ------------- ist n&e to nearest I line_1_....-...-.--_ Linin material - Size: Diamete - Depth. --.--�r------ Number of pits----- t ___'. g t --- Cesspool: Distance from nearest well_--.-....__- Distance from foundation....................Lining material...---------------------------------- V ❑ Size: Diameter--------------- -------------- -------Depth----------------- ------------ ------------Liquid Capacity----------------------------gals. ,y F Privy: Distance from nearest well......;.-,__-....._------------------ ...__Distance from nearest building-----.____-----------------___----- ❑ Distance to nearest lot line----- ------------- ------- ------------ ---------------------- ----------------- Remodeling and/or repairing (d1 scribe)---- ------ ------ ------------- --- -------------------- ----------------------------------------------------------al f -------------------------- ----------------------------------------------------- ------------------------------------------------------------------------------- I --------- •--- ------------------------------------------------------------------- ------------------------------------------------------------------------ - --------------------------------------------------------------------------------------------------------------------- ------------------ - I hereby certify t t I havelprepar his applic tion and that the work will be done in accordance with San Joaquin County ordinances, State la rules an ulations o the San Joaquin Local Health District. s. (Owner and/or Contractor) --- ------------------------------------------------------------------------(Title)--------- ------------------- -- ------- ------ ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be'placed on reverse side). . t FOR DEPARTMENT USE ONLYAj ` APPLICATION ACCEPTED BY_...___ ----------------- - - DATE---------4 �-,-�-------------------------- REVIEWED BY--------------------------------- -F-- ---- ---------- - DATE - ------- ----------------------------------------- - BUILDINGPERMIT ISSUED------------------------------ -- - ------ -- --------- DATE------------------------------------------------------------ Alterations and/or recommendations:-------------------------- -- -------- -- ---------------------------• ---•----------------•------•------------------•------------- - ----------- 5= - r ° t -------------------------=--- - ---•- --- --------------------------------- -------------------------------------- ----------------------------------- ir ----- --- ---------- ----------------- -------------------------------- i ----------------------------------------------------- FINAL INSPECTION $Y: --- --- ----- - -- -- -------- Date. .-{ � �3 t A AQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelten Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California yy I F.F.C9. 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