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FO O F[CE USE: -----------------------.------...... .....rfzp APPLICATION FOR SANITATION PERMIT 'Permit No„C_!Q__7_,( _ (Complete in Duplicate) / - ---------------- This Permit Expires 1 Year From Date Issued Date Issued ___�___ ��1�3 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 Cou y Ordinance No. 549. JOB ADDRESS AND L CATION- = = ----4 k�--r�''�`� � i Owner's Name----c4 ---- -------- --------------------------------------•---------------------------- ----------- ------ Phone.=--..._........---....-=-•----•--- Address---- � ! = . a Contractor's Name..---•-•- ---•-•--------------------------------------- ------------------------------------•-------- Phone------------.---•-•---------------- Installation will serve: Residence f5l,�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /___ Number of bedrooms ___ Number of baths -/---- Lot si e , � __ -�--~------------- Water Supply: Public system {�ommunity system ❑ Private [] . Depth to Water Table A0_, ft. x Character of soil to a depth of-3 feet: , Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ej—Hardpan ❑ Previous Application Made: (If yes,date-----------_--------1 No ®o'--New Construction: Yes. o ❑ FHA/VA: Yes g4-- No Q TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -- I Septic Tank: Distance from nearest well_""- ____Distance from foundation/fl___...........I Material_____/ -- -- --------- No. of compartments p �----------------Size__.._�.�_�`X_�._-_Liquid depth-=4-------------------Capacity.S`:!j[t00 _._ Disposal Field: Distance from nearest well._��---------Distance from foundation-/Q---------------Distance to nearest lot line__ ber of lines_____umi- Al.___-- ' _ �,,�__�__________________Length of each (ine___7�_`____________.1/Vidth of french-------- _. Type of filter.material _df_�_/(-------Depth of fclte material--;/,?'- length-----,fit; __1--______________________ See pag Distance to1`nearestwell__-'�”:___..,__Dista �e4�rom" ou;_ ation-16:� istance to nearest lot line__ _-_______ p Number of pits--------- -----Lining,mater ai -==i�QC,_dt__. Size: Diameter__5.9.`::_..____Dept h__.�t5'r__:______---- . Cesspool: Distance from nearest well------------------Dist 'e,fro undation--------------------Lining material_.._______________________._-_____ ❑ Size: Diameter-------------------------------------Depth_.2'_ _------ -------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest_well...........:..:.» .: _- ._- �_Dis#anee•from-vnearest building_____._______________________..____.____. ❑ Distance to nearest lot line. - ------------------------------------------------------------------- = ft a H Remodeling and/or repairing (describe):----------------------------------- - _____._._____Y'____________ ___ _ ---------------••------------------------ r --------------------------- I hereby certify that / have prepared.+his ap catio an hat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re.guletion }of t $a Joaquin Local Health District. (Signed)----------------------------------------- ------- ----------- } ---. ----------------------------------------- --------------------(Owner and/or Contractor) �. BY: - ---- = ----------- --- -- --- - ---------------l------------=-----------(Title)------------------------------------ -----------:..__ -------- (Plot plan, showing size of lot, location. _ _i „relationjo .eIIs,,buiIdin9s,efc.,_can.be placed on reverse side). r f FOR DEPA TMENT USE ONLY f ow A9 APPLICATION ACCEPTED BY-------- Gtr---- ------------------------------------------------------------ DATE--------- REVIEWED BY ------------ ---- DATE------------- -------•--•- --------------------- ------------------•------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------- Alterations and/or recommendatio s: � ►.1 �r-----------------------------------------------------------------------------------------------------••------- f�. c .W:--------=-------- - ----- --- - ` ------------------ -� ---6 ...=--- ..--- - - --- ... e------ -------------------------------- ----------------------------- -------------- --------------------- x FINAL INSPECTION BY: Date_=---------------------------c ' ----yu--- 1 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,confornia Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.DD. i