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FOR OFFICE USE: ----------------- f (� J APPLICATION FOR SANITATION PERMIT Permit No. ................. ... a� ------------ �i � G --------------------- '-' --. (Complete in Duplicate) Date Issued 4 ----------- ------------------ --------------------- 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 Ordinaric No. 549. JOB ADDRESS AN ATION .0- i / ! 'CSG =�"��`�' ------------------- - ------------ ------------------------------------------------ me ,f Owner's Name -------- ----------. s r }Address...--------- --- ---- ----- ----- --- � Contractor's Na --• -•-• ----- --- I Phone�� ---- Installation will serve: Residence 'Apartment House•❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/-- Number of bedroom-s. lumber of baths J--- Lot size /J ------------------------------------ Water Supply: Public system❑ Community system El Private epth to Water Tablelk ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam E] Clay El Adobe ardpan ❑ Previous Application Made: (If yes,date---"----- I No ❑ New Construction: Yes F1 No A/VA: Yes E-1 No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p stance from foundation--------------------Material-------------------------------------;----------. Set Tank: Not o ofcompartmentsts--.well------------ --SSiize--------------------------------Liquid depth----.--------------------Capacity-------- ��/ t Disposal F' Di stance.from nearest welL. �___".._Distance from foundation.____f Distance to nearest lot line__�._________. Number of lines___.___ ._________Length of each line--_-jam_ _______________Width of trench__ . -_--______________._ { �• Type of filter:material_ITL#T k_---Depth of filter material-------- �_..Total.,length_____ _Q Seepage Distance to nearest well_I------------Distance from foundation___.A.r.___.Dis rce to nearest lot line--------------.-- Number of its_'`_ -----Linin material-"�,r ---_..Size: Diameter__ _ P�__..._.Depth__. r.............. p _� :: g r Cesspool: Distance from nearest well-----------------Distance from oundation----------- -------Lining material------------------------------------------ Size: Diameter.-------=-R------------- `' _--Depth------------------------------------------ .--------Liquid Capacity----------------------------gaIs.I Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--_-_-------.._____________.__I___.-- -. ❑ Distance to nearest lot line--------- -------- -------------------------- ----------------------------------- ------------------------------------- Remodeling and/or repairing (describe)-------- �----- -------------- --- ----------------- - =w,-----___�__..�..,,,..---------------------------------------------------- --- -1 -- -------------•--------------•------ ---------- - -- ---------------------------------•--------------------------- i ------------------------------------ ----------------------•-•---------=----------- ------- ------•---------------------------------------- - I I heytti fy t I have prepared this application and that t e work will be done in accordance with San Joaquin County ordinancla s nd rules nd regal tions of a San Joaqu' oc I Health District. f t \ --------------- ---[Q��rT�dr�dflsrContractor) ) t (Signed}-- ---- ----------------- ---- �- - k BY: -- --- -- - --- - - -----------------•-------------------------- ---------------------- --- - ------------ / ...(Title)--- ---------------------- ----......- •-�-----� -- (Piot plan, showing size of lot, location of system in relation to uildings, etc.,,can be placed on reverse side). ' y FOR DEPARTMENT USE ONLY �`�' ` - - f - APPLICATION ACCEPTED BY---------------------- ------ - V--�----------- ------------------------------- ----- DATE-----�"� -- -- -- -�---------------- ----- REVIEWED BY--------------------------------------------- ---------------------------- DATE--------•-//--------•-r----------------------------- --- - BUILDINGPERMIT ISSUED--------------------------------------------------------------------------_-------------------------- DATE------------------------------------------------------------- Alterations and/or Irecommendations:_. ---------------- --- - -- = - ----------- -------------------------------------------------------- ----�------------ ---- ----�--:- ------v---- --••------- ------------------------- ----------------------------- -- ------ ----------------------------------------- ------------------------- ------ ---- -- -------------- ------- "--------------------------------------- ------------------------------------------------------------- ----- FINAL INSPECTION BY------------- ----- -- ------------ Date...... ------------------------------ SAN JOAQUIN LOCAL HEALTH-DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3•'63 F.P.C17.