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�R OFFICE USE: ------------------------ ------------------ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) This Permit Expires 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. This application is made in compliance with /County j�Ordinance �No. 5j7. JOB ADDRESS AN CATION. l �L--r-c4• ! ,�/// Owner's Name ------------ Phon�"l4 _ '� Address----------------------- - -- ------------------------• .... . -------------------------------------------------------1 ------•-•----------------------------------- Contractor's Name 1 e P I t ..--•-----•--•-•--••-------•-----------•-------- Phone.ZC__j_., .�I-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � Number of living units: ---/- Number of bedrooms _- Number of baths .,____ Lot size .-_(p-. ____}�._._1G _ _________ --- Water Supply: Public system ❑ 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 Previous Application Made: (If yes,date-----------------____) No ❑ New Construction: Yes ❑ No U;,-"FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se ic4T :� Distance from nearest well_________________Distance from foundation--------.------.---Material----------_-------------------------------------- No. ___ __-------__--___-_-___________-No. of compartments--------------------------Size----------------------------•---Liquid depth-------_------------------Capacity-. Di sad- ieldr Distance from near st well___' . 0..f.__Distance from foundation__/Io___-______Distance to nearest lot line______-______ Number of lines_________ __ __� _ __ Length of each line--470_�__ Width of french___.at. y_-._ Type of filter material�a� T__Depth of filter material___-___1_�__-__-.Total length___________ ______ �_________. Jo Seepage Pit: Distance to nearest well------_--------------Distance from foundation--------------------Distance to nearest lot line-----------._-_-- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Z Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material------------------------------------- Size- Diameter-------------4-----------------------De th----------------------------------------------------Liquid Capacity gals. V Privy: ! Distance from nearest❑ well-'__.____--------------------------------------------------------------- .______________________________________Distance from nearest building_____._____________.______-____------ .�Distance to nearest lot line-----` - ------------- ------------------ ----•--------------------- ---------•--•--------------------------------------------------------- - �4 Remodeling and/or repairing (describe)______________ ;______,_. ?., ---=--------------------- -- ----------- �h /�J.__ } -------------------------------------------------------------------------••------------------------ - -- _.-_-;.C��C�!-------_------------------------------------------- r I hereby certify that I have prepared this application and that the work wil be done in accordance with San Joaquin County ordinance to Ia and rule and regulations of the San Joaquin Local Health District. Si ned `r. _ _ .----- ----- --- --- --- - -- r Contractor) (Signed) - 1 --------------{� ) By:------- -- (Title)------------------------------ - (Plot plan, showing size of lot, location of system in relation to we buildings, a _. can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- i--- !Zne-- ------- ------------- --------------------------•---------------- DATE------- ------ ._C' :�� ----------------------- REVIEWEDBY------- ------------------------------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------- ------------------------- ----------------------—-------------------------------------- DATE-------------------------------- - Alterations and/or recommendations:------------------------------------------------------------------------------------ ----------------------------------------------•--------------------------- f ------------------- " � "� "• l a'` c ' ` -`----:--- --:--------- ---------------------------------------------------------------------------------------------------------------•---------------- -------------------------------------- ------------------------------------------------------ FINAL ------------------------------ ------------------------------------------------------------ FINAL INSPECTION BY:-- -------- -I-" '. -------- - ------- ---- -- Date----- " a �-------------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 F.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEC 13.59 3M 3•'63 F.P.CO.