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FOR OFPICE USE: ------------------ ------- APPLICATION FOR SANITATION PERMIT Permit No. . ._ C!__ � ------------------------------------------ ----------- (Complete in Duplicate) li _________________ ___ This Permit Expires 1 Year From Date Issued Date Issued __._.i- ow- - 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. B ADDRESS AND LO TION_/,; __71-- Q ------ .d�'�r•._.. --- !`1 -- ,- :.---- e__ _ Owner's Name-- 4_--- ---- ----'---- ------------------------•--------------_---r-�------------ ! . V Phone---------------------......... ---------------------------------- Address ---- -.. ----------- ------ -- ----------- Contractor's Name--------- t e Phone................. ....... -------- Installation =Installation will serve: Residence E?r Apartment House ❑ Commercial ❑ -Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _) __ Number of bedrooms,; _ `-` / , i t Number baths€___ Lot size ____1�-�/�_-_��r_ `_:.R...r_______b - - s Water Supply: Public system ❑ Community system ❑ Private Depth t Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe El Hardpan❑ Previous Application Made: (If yes,date........... ......1 No ❑ New Construction: Yes ❑ No ❑ PHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - :.>•---� Septi ank: Distance from nearest well--jtX _*---Distance from foundation-------!_Q__!--- -----_______ No, of compartments-_----_7? 7f....._ -----------------Capacify___)-*A- _�,, Dispos Field: Distance from nearest well____��___.-_Distance from foundation____ ___-------Distance to nearest !o} line.S_...._.____. Number of lines___________ _____ _ ___________Length of each line-------�_{�_Q_-_________.Width of trench----2-_°_-_____-______c__._ Type of filterrmafer-ial----. __t ____.___Depth of,filter material_______ r__�_ __Total length_______�__�_(�_�__________�_:-__-_ ------- See a Pit: Distance to nearest well"_IDO---------Distance ffrrom foundation-----1-_D---------Distance to nearest lot line--,-----------i Number of pits---._____y-----Lining-material--Id--.&__:__._Size: Diameter-----L._?_"___.Depth-___/71___________________ Cesspool: Distance from nearest well-----------------Distance from foundation_.--------------.__.Lining material__.___--______-_-_______.__-_-_--_-_- ❑ Size: Diameter--------------------------------------Depth_------------------------------- - - - -------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well._ --------------------- -------_c----Distance from nearest building____________________-__--____-_--_-_.._.. ❑ Distance to nearest lot line------------- ----- --`---------------------------------------------'------------•--------------------------------------------------------- Remodeling - scn e):---- --------------------------------- ---•--•-•-•----=----------------------------------------I-------------------------------------------------------- -----------•-------------------------------------------------------------------------------==----------------------------------------------------------------------------- ----------------------------------------- ----------------------------------------------•--------------------------------------------------•---------------------------------------------------------------------------------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanceS,-State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------- _ � ._ r and/or Contractor) ---- --------- ,� :-By::.-. -' ^- --------------------`_=_ - F� Title)•--=---'-- - == = ------- (Plot(Plot plan, showing size of lot, location of system in relation to wells, buildings,_etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_..__ _.--- _-- ------ --- -- - _ DATE___- - ---- -- -------------- ----------------------- -- ------------------------------------ REVIEWEDBY-------------------------------------------- ----------------------------------------------------------------- --------- DATE----- _--------------- - --------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------- ------ DATE---------=-------------------------------------------- Alterations and/or recommendations------------------------------ ----- ---------------------- -------•-•---------------------- - -------------------••------- --------------------- ------------------------------------------ ----------------------•---•----------------------------------------------- ---------------------------------------------------------------------- --------------------------------------- ----•-- - Ff NAL INSPECTION BY:../fi,--- ------------------- Date_._"-�_.� ---------------- r` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street. 205 West 9th Street Stockton,California Lodi,California Manteca,California ! Tracy,California;:' ES 9 REVISED 5-59 3M 3-'63 F.P.CD. �.