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OFFICE USE: ------------- --- - -------- - - ------------ ---- �+ APPLICATION`%=�FOR'$ANITATION PERMIT Permit No. .. �- C.}--E - (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 Ordinance No' 549. ° 1 i JOB ADDRESS,AN O ATION___3.3 3 .� -- ------- ' - ----- -------- - ------------ Owner's Name-_-.1-_ i•�•i , -----------------e ------------------------= ------ Phone----------------------------------- _ _._i_ _Address---/r _____________--------------- - --------- ------------------------------------------------------- r Contractor's Name-----. ..... ...: . ...... = f ---------------- Phone----•---------••--•------------ s Installation will serve: `Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0 i ri Number of living units:/----- Number of bedrooms,-___Number of baths /___ Lot size _____________-----•- Water Supply: iPubliclsystem Y .Community system ❑ Private ❑ Depth,to Water Table,�Q ft. Character of soil to a depth of 3 feet:�`Sand [] Gravel ❑ Sanidy Loam El ;CIay,Loam ❑ Clay ❑ Adobe Hardpan ❑ ! t fwp #. El Application Made: (If yes,date . .---) No El! New Construction: Yes No FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFI&'fl8_q_Sqq6S: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pf nk: r Distance from nearest well-----------------Distance from foundation______________.__.Material------------------------------------------------- No. of compartments--------------------------Size--- t -Liquid depth--------------------------Capacity--------: 'a---------- Disposal Field: Distance from nearest well.7._Distance from foundation__ a-_-_:____.Distance to nearest lot sjj 1"' .i Number of. lines_____:__r__________ ______ Length_ of each line______-3:.U_.'...........Width of trench------ _--------------------- Type-of .______________ Type of filter material__�_�_ Depth of!filter material___-/g,"_--_-.Total length___-__„ .Q_�_____________ ________ 1�J Dis#ante #o nearest wellyl: --------Distance r�}m fo dation_ Distan ce tonearestlot line__-____-__ d Number of pits �_-----------Lining material--= Size:`Diamsefe,r :_Depth 2S--------------------- Cesspool: Distance from nearest well-----------------Distance from foundation --------- -_-#_.Lining material------------------------------------- ;.( Size: Diameter___ . ___ __ __.De th_.1_ !-1-Liquid Capacity] � - - - ----- -------- ------- p ------------------------- --------------- -'-'----------------'-------gals. o� Privy: Distance from nearest-we'll-------------------------------:___.______ __Distance from.nearest.building---------------_-------------------------- /a ❑ Il Distance to nearest lot line------------------------------i ---=`-------- ------------------ I---------------------=--------- � r G Remodeling and/or repairing (describe):---1 -- --- - - --------------=-y- ---------------- Q j -- --- e: I ,} F I } i - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws; and rules janregulations of the San Joaquin Local Health District-) (Signed)__ ________ __ __ __ Owner and/or Contractor . ----- --------- ----------------- -- By:--------------- -------- --------------------------------------------------------(Title)- ----------- 4............................... (Plot plan, showing size of lot, location of s em.in relation to wells, buildings, etc., caii,be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--____-_ _-- - '�— ---------_- _ DATE-'-- --____�_____ -------------------- -------------- --------------------------------------------- - REVIEWED BY!--------------------------- ---- ----- - =�°_ DATE- ------- ---- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations______________ __ t { ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ i 1 fUt !'", -----•-------------------------------------- -------------- ------------------------------------------------------------------------------------------------- ------•------•-----------------------I------------------------ --------•---- -------•-----•-----------------••----------•---.-.-•---------•--------•---- --------------•-•---•----------------------- --------------------------------------- ---------------------------------------- :may LL FINAL INSPECTION BY:------- �- _r- Date` 7 ' --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California Ikr Es 9 REV16E1] 8.59 3M 3-163 F.P.Ca• S