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v FOR OFFICE USE - y - rr_r ;_ ____ ___ t -` APPLICATION FOR SANITATION PERMIT Permit No. -,i -- --- ------- ------------- - ------- ----------------- (Complete in Duplicate) �� / 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 co`struct and install the work herein described. This application is made in com I+anc with County Ordinance No. 549. JOB ADDRESS AND L ATION B� 25---�S ----------------------------- - - - Owner's Name------------ •--'------ Address------------------------------- ----------- --- g� Contractor's Name----------•-------•-----------•-•----- ---------------- Phone__ --l _ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer, Court F] Motel F] Other x et4 Number of living units: ________ Number of bedrooms -------- Number of bathsR4:i tsize __,11�Lt_�__ � Q_-___________________. Water Supply: Public systemX Community system ❑ Private ❑ Depth to Water Tablelqt>_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,dote--------------------) No ❑ New Construction: Yes ❑ NOX FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e c Tank: Distance from nearest well________________Distance from foundation--------------------Material _____-____---------------__-_____________-_____- _ No. of compartments--------------------------Size---------------------------.--.Liquid depth---------- ------ --------Capacity----------------------- V eld: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of french----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length_________________:_________-__..___-._____ Abir Distance to nearest well ___Distance om f ,ndation__�_�_______-Distance�to nearest lot line______--_-_ Number of pits______________Lining maferial_� ._ ._-.Size: Diameter--- ___.---Depth-__- _----______________ Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material_____________________________________ ❑ Size: Diameter-------------------------- -----------Depth-------- ------------ ----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building:,4__-_-----------------------_----- C ❑ Distance to nearest lot line------ ---------------------------------------------------------------- --------------•------------------------------------------------------- Remodeling and/or% repairing [describe]:_ , _ -__t -s �R �_ ,-----• -�-------------- ---------------- --- - - ---- -; --------•---------------------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinance tate laws, ands es and regulations of the San Joaquin Local Health District. A (Signed J --------- ---- ----- By:- -- { caner and/or Contractor] Sy-----------------------------------•----Pion --- -------------------{Title) (Plot plan, showing size of lot, Iotaf system in relatio to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - - - - - -'�' ---------------------------------------- DATE--------- -.l' --- ---- ----- ---- �--- --------------- REVIEWEDBY------------------------------------------------------- --- ---- -------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED _ DATE Alterations and recommendations:_____-_-._.- � _ - _=_Cr« t �: �_._ _ s z-rr _____._ ---------------------------------------------------------------------------------------------•-------------------------------------------------_-----•----------------------•---------------------------------------------- ----------------------------------------------•------------•----------------------------------------- ------------------------------ -------------- ---------------------------------------- ----------------------------- FINAL INSPECTION G ________ _____ Date__.-._.____ S/ JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca, California Tracy,California ES 9 REVISED 8.59 3M 3-•63 r.p.Cp.