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FOR OFFICE SE -------------- t = 3d 1 Permit No. ff APPLICATION FOR SANITATION PERMIT _-7_---L-- r-`------------ ------- (Complete in Duplicate) Date Issued --1_,�__ - -v_,--- 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 compliancewithCounty Ordinance No. 549. JOB ADDRESS AND LOCA�___�� ------- Owner's ----- ------ k Owner's Name d ' / M-------------------- -- -------- Phone----------------------------------- Address ------- ---------• --------- -------------•--------------------------------------------•--=------- Contractor's Name -P/l -! - Phone---------------------------------- '7 r Installation will serve: Residence [�partment House ❑ Com'mercial ❑ Trailer Court ❑ Motel ❑ Other E] 5 Number of living units: ----J Nu er of bedrooms __�___ Number of aths ----f Lot size _ ®- _-_-__ d._______________________ Water Supply: Public system Community system ❑ Private�epepth to Water Table ft. t Character of sail to a depth of 3 feet: Sand F1 Gravel ED] San dy Loam] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 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 feet.). � _ - Septi ank: Distance from nearest well________________Distance from foundation_-_____-__________.MafeTial_-.___-._--_.---__-_____- _________-_-.-_____. No. of compartments------------------------ ------------------Liquid depth ---- { Capacity Size w `---- Dispose Field: Distance from nearest well---- .-Distance from foundation__ iO------------Distance to nearest lot line___________ [� Number of lines_--1----------------------------Length of each line--------�a--'_------------Width of trench-- :--------------------- , ,.. Type of Cter' material__-4t_L V..__Depth of filter material____ ------ ----- length----------�Z -1-__,-3------------ Seepage Pit: Distance to nearest well___-��---------Distance from foundation-/-,---, _____ .Distance to nearest lot line--/_�_-_-__-__ Number of pits--:--t----------------Lining material---II_o--C.�f --Size: Diameter-- 3-- - --Deptn-------, s�`--------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------___-______ V ❑ Size: Diameter------ ------ --------------------Depth----------------------------------- ------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.-__-____--_.---_____-_____----._-_-- --- 171 Distance to nearest lot line ='. `--_- . ---------------------- Remodeling and/or repairing (descriL�ej:--------------------------------- - -------------------------------------------`-- ----------- = � ----------.. ------------ i ------------------------------------------------------------------------------------ ---------------------- - ----------------------------------------t------------------------------ I hereby certify that I have prepared this application and that the work will be done in}accordance with San Joaquin County ordinances, State la,11, and rules ander gul 'ons of he'San Joaquin Local Health District. i K - -------------------------- (Signed) ----_-(Owner and/or Contractor) ---------- ------ ------------- ---------------- ) I (Title)--------------------------- ----------- ------------------- By:-------------------------------------------- ---------------- ---------------- - ----------------------------- (Plot ------ - --- -- ---- (Plot plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc.,'.can be placed on reverse side). f ' FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY--------`i -------- cy`��-` -_---------------------------- DATE------------/d- -- �� - -- -_ ��------- ---------------- REVIEWEDBY---------------------------------------'..-._._' -------- ----- DATE-----------------------------------• Alterations and/or recommendations: - - �_.., DATE_>--------- ---------------- ----------------------- a :. - BUILDING PERMIT ISSUED_______.___�� - / l • ------ a--.S r-r-� '°� s f� ------------------ --------------------------------------------------- ---------------------- -------------------------------------- --------- 4 r __________________________ ---------------------- - -------------------------------------------------------------- • - - - ------------------------------------ - -- --------------- ------- ------ ------- ------ - --- --- - --------------- �------ FINAL INSPECTION BY:------......_._ -.------ Date --- / `� � � ---------------------- SAN SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E.Na:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Streef Stockton,California Lodi,California "Manteca,California Tracy,California I F.P,C❑.