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FOR OFFICE USE: ------------------ ------------- . } APPLICATION FOR SANITATION PERMIT Permit No. --- -- -------------- --------- ----- --------- - _ 4 _ .(Complete in Duplicate) _1 f I ------ - ------------- 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 Ordinance No. 549. JOB ADDRESS AND LOCATION ( ---------------------------------- Owner's Name----------- _ ------------ ------------------------------- .......Phone.�Pa_` Address---------_-----.......... 6— / Contractor's Name. • - - -�--�-`-------••- -•�--�i+i-�'t�.---�i-�---- -•-��-�----------------------•---------•-•--�-•--. Phone.---•-•-------•---------•--- ---- Installation will serve: Residence zl__Ii4partment House ❑ Commercial ❑ Trailer -Court ❑ Motel ❑ Other ❑ Number of living units: -._1KNumber of bedrooms .`3- Number of baths _.!_-_- Lot size.---Zr--- __f__• _ -__-_.-__--_ Water Supply: Public system Z,-c. ommuriity system ❑ Private ❑. Depth to Water Table _-Pft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er-'Hardpan E] Previous Application Made: (If yes,1.date---------------------1 No ❑ New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ TYPE-OF INSTALLATION AND SPECIFICATIONS: No se tic,tanV or cesspool plermiffed -if public sewer is available within 200 feet. t S I ,T Distance from nearest well-_-----____-___-Distance from foundation________________ Material--_-___-__..__.__..________-_-....t_.-.-_---_-- ,, , No. of-com artments---_ - Size....__-_ Liquid depth ______________ _ ------------ Capacity ------------# C ______�D> tante to nearest lot line ' os�) Distance from nearest well- fle Distance from`foundafion___ Number of line-__�____�- � �_y L`ength ofreach line' =_____- �JAO---Width of french.'__.�A��f..'_________. . .� Type of.,filter material- - Depth of`fiiter material__ t------.----Total, length___________________ .Q-f__---., e a Pit: Diistance to neaest well =F i ✓ ' p #+� ��____Distance fo dation_ ___�4'_�.___Distance to nearest lot 'Number of pits'-'41,1---------------Lining material_ ,-Size. Diameter---��...___Depth---Z.57-----------___ _ �ri1 s � � .� Cesspoo : Distance from'nearest weil_F _____________Distance from foundation Lining material_______--_--____...____:_____.__.__.. # _ [f� El Size: Diameter.' ------- --- -------Depth------ f-------------Liquid Capacify----------------------`-----ga-i Privy' _ Distance from nearest well_____--------------------------------.__-._....Distance from nearest building-----------------____------_-__.____l � ❑ .Distance to nearest lot line r 1 ellIt •- repairing ---------------------------------------- ------------------------------------ -------------------•-------------•-•-----------•-•------------------------ • p g -------------- ---------=-------------•-------------------- --- f --------------------------------------------------------------------- -- f I - --------------------- ---------------------------------..--------------------------------------------•--------------------•------------- -----=------------------- - ---- -- r - I hereby certify that I have prepared this application and that the work will be done in,accordance with San Joaquin County ordinances, .St t lawas, and rules d regulations of the San Joaqu Lacal Health District. : I - (Signe() 5 a 4------- - ----------- ----- - at#/�er�nntractor) Y ; (Title)-------`--------- '- -- -- --- -- --------- (Plot plan, showing size of.iot,;location.of,system in relati to wells, build' gs, etc.,,can be placed on.reverse side). _R t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- 1 ------------------------_-=-------------------------------- DATE- REVIEWED ATE REVIEWED BY - !_'At-- --------------- -•------------ DATE_.---•-------•------- BUILDINGPERMIT ISSUED------------- -------------------------------------------------- --------=------------------------- DAA'E-------------•-------------------------- - - -.. . . Alter tions and/or r com natio s: -----•------- --------------------------------------------------- :. _ ::___ -------�-------------�--- ---------------------- ---_ ___:___: ------------------ ----- } - -__ ` _______________________________ ____{_____ f..._..._._-...__-._..__________.__________._._________.._-_._--_.__----..-----_._•__--._.--_--__- -----------------•---------•------""...___._...__--------------.......-___...._------'--------- -----------4�-----------------------'-----------.....---------------------------------_._,__..._..._-------------------------- ------------------------------------ ----- ---------------------- --------__--------_..------------------------------------------------------------------- --------------------------------------------•----•---------'-------------------...__._------------------------..._----------.--_-------------------------- FINAL _.-.----------- -FINAL INSPECTION BY:--------- -- "r ------------------------------ Date X - -------------------- ------- SAN -----SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E.Haselion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California ES 9 REVISED B-59 3M 3-'63 F.P.CD. :l a