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i FOR OFFICE USE: M y/�- -------------------- 3 ------- ----- APPLICATION FOR, SANITATION PERMIT Permit No. .'i..� .............. {Complete;in Duplicatal i ----- b Date Issued f------- -----••-- --- 3 ----------------- ,This Permit Expires I!Year From Date Issued II 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 C unty Ordina No. 549. JOB ADDRESS AND LO ATIO � " � � r ---- ------------------- - -- -------- Phone---------- ' --------------------- -------------- ------------------- Owner's Name---- -----•--------• --•-------------------•-----------------•----------•---------------------------------- - Y F --------•------------------------------------------------------------- - 0 --- ------------------------ ------------- 7 Contractor's Name-- -------- - -- --- Phone.---•.--•. ------ Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ g Z�Number of baths _1--- Lot size ---�6�a�_�Q�-'-'-----------•----------- Number of living units: _-- ___ Number of bedrooms . I - (� Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Saady Loam ❑ Clay Loam ❑ Clay%❑ Adobe [A-lTardpan ❑ pp ❑ es ❑ No Previous Application Made: (If yes date_-------------- - -) No New Construction: Yes No FHA/VA: Y TYPE OF INSTALLATION AND SPECIFICATIONS: sviable within 200 feet.)(Nse tic tankcesspoolp • if public sewer I Sept' nkDistance nearest well-----------------Dis# 'ce from foundation--------------_--.Material--------------------------------.-----------_--. No. of compartments-------------------------Size--------------------------- ---Liquid depth_--- ...-------------Capacity----------------------- Disp Field: istance from nearest well------------------Distaan,ce from foundation-------------------.Distance to nearest lot line----------------- Number of lines------------•----------------------Length of each line-----•------------------------Width of trench---------:f___-.--------------------- f Type of filter material-__-.---___ p of filter material------ Total length---------------��:----------- -_--- / ------ Seepage Pit: Distance to nearest well-- _-D stanc�om foundation/®--r--_-.- Distance t9 nearest lot line__-------_ r Number of pits---I-----------------Lining material----l=4-QG''�=_.Size: Diameter - Cesspool: Distance from nearest well-----------------Distance from foundation--------.__..-_._---Lining material---.------- -------------------------- El _------_-------.❑ Size: Diameter----------------------------- ----Depth-------------------------- ------------------------Liquid Capacity------- ------------------gals. Privy. ❑ ----------------------Distance from nearest building_--------- ------------ ------------- Distance to nearest lot line---------------------------------------------- ------------------------------ - -------- ---- --------- Distance from nearest well_-------.-___---.. Remodeling and/or repairing (describe):----------------------------------------------- - ------------------------- ------------- -----•• ------•----------------------------------••------------ ... — -- --------------- ------ ----------------------------------"--------------------------.----------------------------------------------------------i----------------------- I hereby certify that I have prepared th' application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and tions of he San Joa uin Local Health District. E A - ---------------=---(Owner and/or Contractorl (Signed) - - ----------- B ----Y------ - ----------------- (Tif le)------------------ --- -------.---;7------ - ------ -------- Plot Ian, showing size of lot, location of system in relation to g p l Y----- -- -- - ( p g I wefts, buildings, etc., can be laced on reverse side), ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---� '�-f ---------------------- - ---- - DATE-------------------- it BUILDING PERMIT ISSUED------------------------------------------------------- - -------------------------------- - REVIEWED BY----------------------------------- -- ----------- --- -------------- Alterations and/or recommendations:.----__:.__------- ----- I i - ---------f-------- --------•-•------------------------------------------------------------------- •---------------------- 4 ------------------ i- - ---•------ -------•-------------- ---------- Ir Date- �':--- ------ ---"� FINAL INSPECTION BY:..- -- ,! - `l > y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California I ii ES 9 REVISED 13-59 31A 3-'63 F.P.Cd- l