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FOR OFFICE USE: ---- - �--�------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------- ------------------------------- (Complete in Duplicate) /o 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. 1 JOB ADDRESS AND LOCATION.____?7_,r--___�___._/_/_�� - 4"�----------------._ Owner's Name_' ------------------------------------------------------------ -------------------------------------------- Phone----__---------•----------------•--- Address__________ __ _ Contractor's Name_--- - � 7� ---------------------••-•------•------------------------------------- ---------------------------------------•- -- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living � __its: -_„,Number of bedrooms .,3--_ Number of,baths is __ Lot size Water Supply: Public system El Community system [-] Private Depth to Water Table - _aft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe "Hardpan ❑ Previous Application Made: (If yes,clate-/�r-�-�7—j 1 No [3 New Construction: Yes [:] No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFIMIGMS: ✓ (No septic +ank or'cesspool permitted if public sewer is available within 200 feet.) Septjr.,T1 an6w. Distance from nearest well-----------------Distance from foundation--------------------Material ______________________________________________- i JLL No. of compartments-- -----•-------- ---Size-•-----•-------•-------•-------Liquid depth-------- ------_Capacity-------------------- Dispos 'Field_:' Distance from nearest well.,_5_D.___._Distance from foundation_ �.:?Q______.__Distance to nearest lot line__ ....... [ Ali a�"'• b Number of'lines---.-. --- --- e, per/ Length of each line------.�G- Width of trench----- Type of filter material____��/�--__Depth of filter material___./'' -__-.._.Total length_-!_-,�-Q_-___-___�"_____________ Seep Pit: ,Distance too nearest well-_.__---____________Distance from foundation.....................Distance to nearest lot line----------------- 1 4 umbfer of pits----------------------Lining material----------------------.Size: Diameter---------------.-.----Depth--------------------------------- 00 Cesspool-: i �, Distance from nearest well---------------_-Distance from foundation---.----------------Lining material-------------------------------------- u1 ❑ 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):_____..._. ' E+ = 1______ _______. `?_. ----- --- 'L______________ y, I# ---- ---------- - ------ VW ----------- �' --------- ' ------------ 1 A w ------------------ ----------------------------------------------------------------:---------- -------------------------------------------------------------------------------------------------------------- I I hereby certify that I_have prepared this application and that the work will be done in accordance with San Joaquin County ; ordinances, State laws, and rules-and regulations of the San Joaquin Local Health District. (Signed)-------•------------------------------ -.-- '------_ __ (Owner and/or Contractor) - - --- ------------------ ---------=----=----------- ------------------------------- ------------- By:-------------'-------- --------------------;----------------R-----------------------------------------------------------(Title)------ -- --------- ------------------------- ------------------ [Plot plan, showing size of I location of sys+em in relation to weNs,.buildings. etc., can be placed on reverse side). 5 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE'---------------------- REVIEWEDBY--------------------------------------------- ------------------------------------------------------------------------------•- DATE--------------------------------------- BUILDING ----------------------------------- -BUILDING PERMIT ISSUED--------------------------------------------------------------—---------------------------------------DATE_------------------------- -------------------------------- ---------------------- Alterations and/or recommendations-------------------------------------------------------- ------------------------------------------•-•------- --------•-------•------------------------------- -----------------------------------------------------•------------ -----------------------------------------------------------------------------------------------------•---•------ ---------------------------------------- ---`---------- ----- ------------•- ------ --------------•-------------------•----------•--------------------------------- -------•-----------------•-------•-----------------------•----------------------------- -------------- -•-- FINAL INSPECTION BY:_. . -r�'-------------- bate-----A/0I&;- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Hazellon Ave. 340 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED B-59 3M 3-•63 F.P.0O3