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FOR OFFICE USE: -------------------------- ----- ------- ---- '-------- -------------------- ---------------- -------------------------------------------- ------------------- APPLICATION FOR SANITATION PERMIT Permit No. -41 --- -- (Complete in Duplicate) IS� --------------- ---- ---------------------............. This Permit ExRires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construeand install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L9j4ATION I / �-� - ---------------------- a Owner's Name------ •------ -- - Phone------------------------------------ Address ---------------------------`--------------------•-------------------- Contractor's Name--- -------- - -- -- _ ------ Phone-----...--.............. --------- Installation will serve: Residence Apartment House ❑� C mmercial ❑ Trailer Court [] Motel ❑ Other ❑ ;Number of living units: -� umber of bedrooms - --_.- Number of baths - f Lot size _-- 4--_x.-- - ------------------------- Water Supply: Public system Community` system ❑ Private E] Depth ater Table .1 ft, ft. t � i Character of soil to a depth of 3 fee+:=Sand E]'i Gravel 0-Sandy-Loam -Clay Loam-[] Clay ❑ Adobe❑ HardpanEl Previous Application Made: 11f yes,date._-_.!-------------1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION 'AN D-SPECI PI CATIONS: o (No septic tank or c-blipoo permitted-if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well------L----------Distance from foundation------------_.......Material-------------------------------------------- -. / ❑ _No..of_compartments---------------' `----Size--------------------------------Liquid depth--------------------------Capacity---------------------�-- Dispos field: Distance from nearest well----`'1'"`-----Distance from foundation-----/0.------.Distance to nearest lot line---- _-- - Number of lines----_------_/-,1-_ -------_Len th�of each line.._--- - Width of trench----IV-*------------------------ fi Type of filter.material--{%S!x'—t---_--_Depth of filter material------& -------Total length-------- Q-----------------------1__ �+ � 5eepage Pit: Distance to nearest well----------------------Distance from foundation-------------- Distance to nearest lot line--._---.----_. ❑ Number of.pits------------- --------Lining material----------------------.Size: Diameter------------- -.------.Depth-.----.--.------ Cesspool: Distance .from nearest well------ ----------Distance from foundation.-._.-.--_----.--.Lining ma-terial__.----_--------_-----.- ❑ –Size: Diameter-;'--------- -----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. y❑ well Distance from nearest building Priv ! Distance ram nearest -------------------- --- - --- -------------------------------------------- ------------------------------- ' .i Distance to nearest lot Remodeling and/or-repairing (describe):---±i- r ----------------------`------------ ----------------- --------------- I hereby certify that I have prepared this,application and that_the,work.will be-done in accordance with..San Joaquin Country --ordinances, St aws, and rules and regulations of the San Joaquin Local Health District, i I (Signed}----- ------- --------------� ----- ------- ------- '.and/or Contractor) ----- B •- ---- --- ----------------------------------------- ---- Title --------------------------------------- ------------------------ (Plot --- ------------------(Plot plan, showing size of lot, location o s tem in re(at +awefls, buildings, etc., can be placed on reverse side}. VVV FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY-- �e -------- -----------------------•-----------•---- DATE---- �- -- -^�.1 :-- t REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE--------------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------- --------------------=---------------------------------------------- DATE-------------------------------------------------------- -- Alterations and/or recommendations-------------------------------------------------------------------•------------------------------------------------------•-••--•---------------- -------- -----------------------------------•-----------------•------ --------------------------------------------------------------------------•----------------------------------------•-------------------- -------------------- FINAL INSPECTION BY:.. _._.-!;a-l. ----------------- Date_" _��..". k I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street a r Stockton,California Lodi,California Manteca,California Tracy,California , ES 4 REVISED 8-69 3M 3-'63 F.P.DD. 1 I