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FOR OFFICE USE: -� ------ - • _��`��- -------------------_-----------------__ APPLICATION FOR SANITATION PERMIT Permit No. ------ -------- -------------- --- (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 construct and install the work herein described. This application.is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI. -- --dj6lj.& Owner's Name j� " � --------------------- Phone ----------- Address !, - �TQ'+�- r� // /L ------------------- one-- _ --------------- -1 -------------- Contractor's Name -s.. L --------- Ph -- -- 1 -•---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ units: Number of living ___� Number of bedrooms Numz 'baths __._____ Lot size _____.__ _______________ __---- - ---------- Wafer Supply: Public system ❑ Community system El Private epth to Water Table _.------ ft. Iter of soil to a depth of 3 feet: Sand ❑ Gravel F1 Sandy Loam [I Clay Loam ❑ Clay [j Adobe [3 Hardpan Character p Previous Application Made: (if yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) Septic Tank: Distance from nearest well-________________Distance from foundation-------------------.Material------------------._______-_______--.-________-_. ❑ No. of compartments--- - -------------------Size--------------------------------Liquid depth------------ ------------Capacity---------------- � Dispas field: Distance from nearest well----' S�-Distance from foundation___/_b_____------Distance to nearest loot`ine_ __-______ Length of each line---_/ v--�--- ---.Width of trench----------------- 9 -------------- --�------------•- Number of lines___.______._r_._C_-�--- 9 - - - - rr Type of filter material------ J5 _ ____Depth of filter material_______._(_ _______Total length___.____.__1_ ------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------.----------.Distance to nearest lot line------------------ Number of pits----------------------Lining material---------------------.Size: Diameter----------------- ---- Depth---f---------- ------ OOF Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----- ------------------------------- ❑ Size: Diameter-------------------------- ----------Depth--------------------- ----------------------------Liquid Capacity------------------------ gals. Privy: Distance from nearest well-----------------_-------------------------------Distance from nearest building---------;,---------.--_______-__.._--_--- ❑ Distance to nearest lof line--------=--- ---------- ------------------------------------------------------------------ -- Remodeling and/or repairing (describe)---------- ------ -------- - - --------- --------------- ------------------------------------------------------•-•------- -------•------------------- - -------- -------•-----------•'--•�----'-- --------------------------------- r-'---------... --- ----' ----------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CounfN ordinances, State rand rules and re ulafions-of the San Joaquin Local Health District. `X r Contractor) 41 (Signed]_ = I - - - ---- A --- -- . . -_ - -----"{Tit e� B � o rte__-___" -_-- -------- -- -------- -------------------- (Plot plan, sh wing size 0f lot, location of s tem in rete�,,�nfowells, buildings, etc., can be placed on reverse'side). Q FOR DEPARTMENT USE ONLY 4, APPLICATION ACCEPTED BY-- Fr ---------------------- ---------C-------------------------- DATE--- --- --- ------- REVIEWED --- =REVIEWED BY--------------------- --------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------- DATE -------------- Alterations and/or recommendations:------ ------- -------- ------ r ° ---------------•------------------------------- ---------------------- r FINAL INSPECTION BY: • ------------ Date...__ •- � � _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th 51reet Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISER 5-59 3M :3-'63 F.P.CO. :_+s