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FOR OFFICE USE.,, -- -•---- -19* ------------------ -------------------------- 1, 3' APPLICATION FOR SANITATION PERMIT Permit No. _._•---=-----:-••- :- --------------------------------------------------------- (Complete in Duplicate} �. ------------- This Permit Expires 1 Year From Date Issued Date Issued __..___�...........: Application is hereby made to the San Joaquin Local Health District for a permit to construct a install the work herein described. This application is made in compliance with County Ordi ante No. }549. JOS ADDRESS AN LOCATION........ ••-•----••----•------------------- y Owner's Name... .--- •• - --• --- ------ - ----------------------• -----••----••-- ----------------------------•-----------•------------------- Phone---------------- -•----•-•••-•-•-•--- Address.. ................ -- ------------ _2-------- ---• ...... ---------- ---•- ---` ----- ----•-------- ----._ ..........•... Contractor's -•-- -- Phone---f•.-- Installation will serve: Residence Apartment House [-] Commercial E] Trailer Court ❑ Motel ❑ Other C1Number of living units: __ _____ Number of bedrooms ...Z Number of baths __/_. Lot size ..... .... ......1 1. _..._____--_____. Water Supply: Public systemT!�"Community system ❑ Private ❑ Depth to Water Table _._____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe/& Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ NoS5_ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) fjc T nk`� Distance from nearest well_________________Distance from foundation___________________.Material__________:____________-_--------------------.--- t. No. of compartments--------------------------Size---.--.-._-----------.-.--- ---Liquid depth--------------------------Capacity............. lsposal Fi Distance from Weare t well_1 .Q Distance from foundation_____ ------.Distance to nearest lot line'__,.. AO Number of lines________ __ Length of each line____�_X____ _ Width of french__S�_�_�____-_-____•__ ,J - --------- �/ A .f Type of filter material_'_____ _________Depth of filter material_____�,�_ __�otal length____.l�___.___________________-� Seepage Pit: Distance to nearest well------ -----------Distance om foundation----"�.............Distance to nearest lot line-------- Number of pits....�----------------Lining material____ _ �......Size: Diameter.._._•_. ______..____ ..___________ Cesspool: Distance from nearest well-----------------Distance I oundation--------------------Lining material..__._.___-__-______._________:.--_-_ ❑ Size: Diameter--------------------------------------Depth----•-----------------------------------------------Liquid Capacity----•-----...................gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.-.-...-------------__................... ❑ Distance to nearest lot line---------r--------------•---------------------------_..-.---•--------------•----------_..------------- Remodeling and/or repairing (describe)--------------------------------------- -------------------------------------------- ---------------------- -........................------•......... .................••----•----...---------------•--------•------••-----------•- -------- - --- /-•------_----•.------••------------------ • j�' ------------•----------•---------------- - ----------------------•-------------------- •--------•---..--------------•------------------------------ ------•-•---------- - --------------------------------------------------------------------------------- I hereby cerfifY t t I have prepared this application a that th work will be done in accordance with San Joaquin County ordinances, St an ules and reg lations i ocal Health District. [Signe ------•- ----- ---------- -------- --•-•--• - - ----- ---- Contractor) $Y:------_-----------•----------- - -----------•-•-------•--------------------------------- - --------- --------(Title)------------------------------------------------- -------------- (Plot plan, showing size of lot, location of system in relation f ells, but dings,, can be placed on reverse side). R DEPARTMENT USE ONLY oe APPLICATION ACCEPTED BY.... DATE... ---•------------------ ---------------------•- •------. _ .._...--- DATE----------••------------...----- REVI EWED BY ••--•--••-----...--- •-•-/7-------------------•----------- - • -- .............---•--•-•---•-•------ BUILDINGPERMITISSUED...................................... .•-------------- – ---------------------------------. DATE------------------•-------------•----- -----------•-------- Alterations and/or recommendations:_3---)4.-,_+w,_____: - --Li_ .__ tea..._..... �vj----------------------------------------------------- ..................................-------------------------- -- ---------------------- - --------------- --------------- FINAL INSPECTION BY:--- ((fl"- Date--- _l. (-�------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Strut 300 West Oak Street 124 Sycamore Strut 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 0 REVISED B-59 YM 5-61 ASkAS