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If FOR OFFICE USE: ------------------ ------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. o�!J............. ----------------------------- ------ ---- Complete in Duplicate) / I Y.`-.___ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to ahe San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in co pliance with County Ordinance No. 549. Y 0t_ , /I glt-7d I .� .r JOB ADDRESS AND LOCATION---------- ------------- 't'` =E'----' '"" ---------------------------- ------- Owner's Name------ ^----•--'"1_.LtL ---------------- Phone------------ �/,� ------------------ -- -•----•------ 0,57 k Address . ---.•... - ------- ---------• ----------- ..� • � _�f�.?i'--- Contractor's Name-----1 - - -- 4`` -^x,------- Phone. - Installation will serve: Residence O[ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 40, Number of living units: -------- Number of bedrooms _ Number of baths .. - Lot size ._.�J:/-=-.-.-- -•.. �`----------------- Water Supply: Public'system X Community system ❑ Private [] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.0 Clay Loam ❑ Clay ❑ .Adobe P< 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.) r Septic Tank: `Distance from nearest well, --Distance from foundation.__��.. .-_-- Material------------------- ----- --------_-------.-... ❑ No. of compartments-- ------- �k`/- ------•-------Liquid depth-------jF- ------------Capacity../��Q------ �„ - ----Size-- -- --- Disposal Field: Distance from nearest well-/w?,9...._.Distance from foundation_..e��.__ ..Distance to nearest lot line_.__6-----.--- k . --r ❑ I)1um4jer of lines------------ ---------------- --Length of each line------,c0.--/--��7--.-...Width of trench.-----a•1�- -.- ---- Type of filter material-----/t Depth of-.filter material_/-f2t ,;?,V�!Total length-__ ,�4._........................ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits.------------,--------Lining material-----------------------Size: Diameter-----------------------Depth-------------------------------_ Cesspool: Distance'from nearest well.................Distance from foundation--------------------Lining material...----.-------.-.-------__._.__.._... ElSize: Diameter----- -------------------------------Depth------------- -------------- Liquid Capacity gals. - .... .........Distance from nearest building -- Rrivy: = Distance'froinnearesfi well. .- ------------ --------------- ❑ Distance to nearest lot line-----------------—--------------- ---------------------------------------------------------------- ---------------------- -t Remodeling and/or repairing (describe)-------------l��.. ---��=�-`--C4.,��=��-�---,C��f ------------------------- ---•----------------•- ------------- --- --- ----------------------- ------------------------------------- ---------------------------•--------•--------•-------------------- --•---------------------------------------------------------------------------- ---------------------------------- ---------------------------- --------I------=-----------------------------------•---------------------------------------••--------------------------------------------------------------------------- ------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ... ---------------- ------------------------------------- (Signed (Owner and/or Contractor) } BY=-- i r {Title) (Piot plan, showing size of lot,.locatibn of s t in relation to wells, buildings, etc., can be placed on reverse side). l FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- jREVIEWED BY---------- I- - --------- --- ---------------- --------------------------- ---------------------=----------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------=------------------------- DATE----------------------------------------------------------- Alterationsand/or recommendations--------------------------- --------------------- -------------------------------------- •---------------------------------------------------------- ----------------------------------------------------------------------------------=-----------------------------------------...---------------- ---------------------------------------I---------------------------------- -------;--------=------------•---------------------------------------------------------------- ----------------------------------------- --------------------------------- ------------- ---- - } ---- . ... .. - ---- - -------- t� FINAL INSPECTION BY----=---------- Date---- I SAN JOAQUIN LOCAL 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 C5 9 REVirrD 9-59 3M 3-'63 F.p.CD.