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FOR OFFICE USE: sr961 i Z ------------------- ---- ----------------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------_ . , _----------------- -------- (Complete i e r From Date Issued Date Issued ... Duplicate) This Permit Expires 1 Year . 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. p JOB ADDRESS A LOCATIO _ � - -- --- - -- --- -- - •-- --- --- ---�'-=-� -� �` ---_-=-- ------...- •- ------ r`s Name r ---------------- ------- ---•----------------• -- -Owne w . Phone jhone i Address ' L1+v - --- -------------- ••------------------------------ Contractor's Name------------- Phone----------------------------------- --------------- e Installation will serve. Residence Apartment House ❑ Commercial ❑ Trailer ourt,� ❑ Motel ❑ Other ❑ Number of living units: .__ Number of bedrooms - Number.Depth baths _______. Lot-size _________ ----- ____ ___-________ Water Supply: Public system E] Community system El Private to.Water Table _. ___ ft. r 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 ❑ 1' No ❑ FHA/VA:.Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 4 (No septic fank.or cesspool permitted if'public sewer is available within 200 feet.) Septi ank: Distance from nearest well_w��_-_-__Distance from foundation____/&0--�_____.Matanal___ __._ ____ _ __ ___-----------------_ r _ < 11' 9 f No. of com compartments Size _-Liquid depth---- - Dispo I Field: Distance from nearest Distance from foundation._ �09�_____-Distance to nearest lot lina- -- ; � Number of-lines___-_--�....__- Length of each line-------,lv-v--_-_____ z! -.Width of trench-__.v9__ / ----------- ......... h Type of filter material-_ ____.Depth of filter material--------/1F_`�___-Total length------ -------------------- Seep e Pit: Distance to-nearest.well-----/AC?,f?__`--Distance from foundation_ �_._/' _/ � ___.Distance to nearest lot line __S__. Number of pits____,C,2_ � ,p , __..___.__Lining material-4-11P _ _______..Size: ._--r__..__Depth_._ "___-------_________ Cesspool: Distance from nearest wefl---------------=-Distance from foundation------------.-------Lining material----------------------._.____-__-_._ Size: Diameter------- ------------------ -----------Depth----------------------------------------------------Liquid,Capacity----------------------- gals. ^. Privy" Distance from nearest well--------------------------------------------------Distance from. nearest building-------------------------_.:-;':-'.__._. ' ❑ Distance to nearest lot line------------ ---------------------------- - ---------------------- ="= Remodeling and/or repairing Idescribe)_---------------------____3_ 4 ------ " 1 ---- t ------------------------------- ---------- • , ----------------------------=------------ ------------------------------------- -- --------------------------- --------------------------------•--- I hereby certify th have prepared this application and that the work will be.done in accordance with San Joaquin County Y ordinances, State law , an rules and regulations of +he San Joaquin Local Health District. '^ (Signed) --------- --------5------------------------------ ----------------------- er and/or Cont cfor) ------ ------ g _ ---- ------------------------------- Piot Ian, showin size of lot, location of system in relation fo.vrells uildin a, efc., can��itle) ti ••- �- ( P g Y i g-k be placed on reverse side). r FOR DEPARTMENT USE ONLY �- »-- - , N - DATE-�_ — APPLICATION ACCEPTED BY -- l - --`�---- - � REVIEWEDBY---- ------------------------------------ ----------------------------- ----------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------------------ J DATE �,. Alterationsand/or recommendations:------------------------------ ----------------------------•--•----------------------------------------------------------------------------------------•------- -------------------------- ----------- ----------------------------------------------------- -------------- ---------------------------------------------------------- ----- -------------- --------------- ---------------------- - - ------------------------------- ----- -------------- --_-,_---I------------------------------ - ----------_----- - ------------------ ------Y-- -•----------- i FINAL INSPECTION BY:--- - -----. - --------------- Date------16 - - -. -- SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 5-59 3M 3-'63 F.R.CO.