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FO7RYR.. USE: __________ /_ ----- --- { APPLICATION FOR SANITATION PERMIT Permit No. '. o ------------------------------------- ------------ §• - (Complete in Duplicate) Date Issued --- ---------------I- -- ------------- --- - -------------- _G------------------------____.._____-_.___..____.__. 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. i This application is made in compliance with County Ordinance o 549. JOB ADDRESS A CATION----- � -----•---- ----------- 11 Owner's Name--- ----------- • - -------.----------------- ,- ---------------------------------------------------- Phone----------------------------------- Address-------- f - C ¢ Contractor's Name— --- � - - -• �'—� ------'---------- I Installation will serve: Residence [�artment House E] Commeraal Trailer Court ❑ llMotel E] Other ❑ Number of living units: ---- Number of bedroomsl'-�Number of b �hs._/_,_ Lot size --- T- Water Supply: Public system E] . Community system [I Private Depth to Water Table _• ft. Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made:. (If yes,date----------- _._.1 No ❑ New Construction: Yes ❑ No �A/VA: Yes ❑ No ❑ F INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.} ep i:T 6.. Distance from nearest well-----------------Distance from foundation__._.-.-______.____.Material"___________._._______-________._.____________. No, of compartments----------------- -------Size`--------------------- •--------Liquid depth-------------------------Capacity----------------------- a os Distance from near f well :0.__-_-Distance from foundation---/_0-_.:-___Distance to nearest 1 tfliinne_--�----- Number of lines___t7___ ---_ ______ Length of each line__"--- �«---..Width of trenchr `'_.��------r______ 16� --------- Type-of filter material ` ----Depth of filter material____ _�'___ _r_Total length---_---------------- �_-__._____ pa Distance to nearest welL.rQ�I__..- .___Distance rom foundation------/a_____Distance to nearest lot line__._.- Number of pits----I---------------Lining material f, '_.__.Size: Diameter- ' ��Depth------EliC � Cesspool Distance from nearest well_,:__.__________Distance fro foundation_._-_______.'__---.Lining material-------------------------------------- El Size: aerial___________________________._._____- Size: -Diameter-------------------------- -----------Depth---------------- I----------------------------------Liquid Capacity----------------------------gals. A Privy: Distance from nearest well----------------___-------------------.----------Distance from nearest building---__._.__________--___-_______._"-_._._. ❑ Distance to nearest.lot line"- --- --------------------------- --------------------------------------- ---------•------------------------------------------------------ 1 deling and/or repairing (describe):-_-- ----------------------------------- -- -------------------- -•- -------- --------- , _--••-----• --------------------- - - ---------- -- ------------- - --1 -- - -----.----- - -' ----------------------- ------------------ ----------------------------------------------------------- �•- -------------------------------------- -- ----------=---------------------------•---------- I hereb ertify that I have prepared this application and that the work will a done in accordance with San Joaquin County ordinance t lte la and rues and regulations of the San Jo in Local He District. (Signed} + C ---- or tractor] By=------- ------------ ----------=------------------ --------- - ------ -----------(Title)------------------------------ --------------- (Plot plan, showing size of lot, location of system in relati we Is, buildings, c., can be placed on reverse side). f 'FOR DE TMENT USE ONLY APPLICATION ACCEPTED BY-- ----- : ,- r --------------------------- DATE-------- __ ` REVIEWEDBY----- ----------------------------- -------------------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------•-- --------- ----------------------DATE---------------------------------------------I--------------- ---------- Alterations and/or recommendations:------- ---------------------_ ___..-----------------------• T -------- ' �P'C�`2.`� ------ r-1.C'-------------------------------------------------------------------------------------- ---------------------- ----------' -------_------•------------••--•-------------------------------- ------------ -•-------------"----------- ------------------------------ -------------------- --------------------------------- --------- -•---------------•-------------------- -------------•------------------- -----------------'-' - - ---- ' ' - -- ----------------- --•---- ---------------------------- FINAL INSPECTION BY: ate ' AN JOAQUIN LOCAL i 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 8-59 3M 3-•63 F.P.OR.