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FOR OFFICE YSE. '' �;- ----------------- ------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .f.�._�D. ----------------------------------------------------------- (Complete in Duplicate} r//y --------- --. I This Permit Ex ires 1 Year From Date Issued Date Issued ..... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION...--` - ----A.-vo..--•--____-- Owner's Name.. + -L 1..._.. �LQ :�P!n -------................... .. . Address-------------------- �sE - Contractor's Name +.. ._4 ---/6P `__ _ _ __. '�______________________ PhonePidr3y � Installation will serve: Residence', Apartment House ❑ Commercial ❑ Trailer Court ❑. Motel ❑ Other ❑ Number of living units: _l____ Number of bedrooms 1----Number of baths/__ Lot size ..,_ 5720-___._.1�..._.. Water Supply: Public system-4 ystem Community system ❑ Private ❑ Depth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�Hardpan Q Previous Application Made: (If yes,date----------- --------) No ❑ New Construction: Yes ❑ Ndj_FHA/VA: Yes ❑ No ❑ TYPE,Qj INSTALLATION AND SPECIFICATIONS: No�sepfiic-�tank or cesspool permitted if public sewer is available within 200 feet.) c a Distance from nearest well....................Distance from foundation--------------------Material_______-______--____-_-_ No. of compartments--------------------------Size-------•-------•-------------Liquid depth--••---....--------------Capacity--•----•---------- ' osal Id: Distance from nearest well-_i�D-�Distance.from foundation__._ ._t!� Distance to nearest lot Number of lines_____ _____ ____ Length of each line_ Width of trench___S _�r_.4_��__.______... Q4)- •... ... Ri Type of filter mat erial.. Depth of filter material _____________Total length... .... jr �""" -- -•--•---...---•--- Seepage Pit: Distance to nearest well_Ralt, ____-Distance from foundation__1�_ .r._..D' t n#, to nearest lot line..__.F_.._..�_.. Number of pits__.----------------Lining material_ Size:. Diameter___ ' _____.__-.Dept ... Cesspool: Distance from nearest well-----------------Distance fr m foundation-------------------.Lining material..._.______-________________-_----_-_ r ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----------...............gals. 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____________________._....-----_-_-.___._- ❑ Distance to nearest lot line---------------------------•------- ------------------------------------------------------------------------------------------._------------ Remodeling ..---•-- ---Remodeling and/or repairing (describe): --------- ----------------------- -------- ......................... ------------------------------------------- - -------------------------------------------------______------------------- ____,-----------------.----------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to la and rules and regulations of the San Joaquin Local Health District. t _____ _._ 1. .-. .. .. -�� ------- By: ------------------------- (Signed) �It *�.OntraCtOr) By:.........................................................------•--------•------------- - - � --------- --- -- Title)---------------------------------------- --- ---•---- (Plot plant, showing size of lot, location of system in relation , buildings, etc a be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -------------------------------------- DATE---- REVIEWEDBY------------------------------ - --------------------------------------------------------------------------------------__ DATE-----------•-------- --.-..-------------------------------- BUILDINGPERMIT ISSUED--- -----------------------------------------------------------------••------_--•-------........ DATE... ------------•------------------------------------------•- Alterationsand/or recommendations--------------------------------------------------------------------- ----•----•---•--------•-------•----------------------•-------•-------------...._.-------- T ------------------•-------------------------------------------•------•-------_--_----•---•----------....._----•-•---------.... ----------- `-- --------------------------------------------------------------------------------------•-•---•-----------------•---------------------- .............. ----- ---...---- ------------------------ ---------------------- FINAL INSPECTION BY: Date �'Z --•--- ---------------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West oak Street 124 Sycamore Street 305 West 9th street i Stockton,California Lodi,California Manteca,California Tracy,California E-S 9 REVISED 8-59 YM 5-61 ATLAS w