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FOR OFFICE USE: y ----------------------------- ---------- ---------------- ------- ----- --------- ---------------------------- ---------------_.___-_-------------------- ---------------------_____._ APPLICATION FOR SANITATION PERMIT Permit -------------- ------------------------------------------ (Complete in Duplicate) Date Issuedi�� --- ----------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION ......_-------------------- ��--- ........................................-... ....--------------•-••---- -� vim? Owner's Name-"------1---.-.7..V.. ,l-I e 6 � t�� ----------- �y Address. .? � �-r ----_-- ----- .... ........................................ Contractor's. Name------e unt._ `--- ................. Phone.`:i��_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court (] Motel ❑ Other ❑ Number of living units: _ -�__ �____ Number of bedrooms - __. Number of baths ..-K-. Lot size ---- l_`�__ �C __ __.___. !'�,�.�_____________ _______ . � Water Supply: Public system ❑ Community system [I Private',( Dr epth To Water Tablet. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 0 Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------I No X New Construction: Yes ❑ No FHA/VA: Yes ❑ NOM j TYPE OF INSTALLATION AND SPECIFICATIONS: -- - (No-septic tank-or-cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation....................Material-______________-_______------------.....____..__. ❑ No. of compartments--------------------------Size-------------------------------.Liquid depth--------------------------Capacity--------•------•----. Disposal Field: Distance from nearest�weli------------------Distance from foundation....................Distance to nearest lot line____________•---- ❑ Number of lines------------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material------------------...-.Total length--------------------.-------------------.- Seepage Pit: Distance to nearest well__ Q .�.-__--Distance from��, un ation___::rte©.-.___.Distance to nearest lot line_��r--Number of pits;_________________Lining material__/r ._ Aize. Diameter_4��Depth___._124- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------._._-_--..__.___.___. ❑ Size: Diameter---••---------------------------------Depth----------------------------------------------------Liquid Capacity-----•--•-----------------gals. Privy: Distance from nearest well----------------------------------.--------------Distance from nearest building______________________•---.--_--__-_____. ❑ Distance to nearest lot line--------------------------------------------- - -------------------------------------------------------••---•-••---•------------------------•--- I Remodeling and/or repairing (describe):------------------ . ate`' -rt'�!'c.,_"`�} .[ . '�.,.............. -------------------------------------••-----------._._.._-------•-------------------•----------------------------•-•-----...........-.........---------------------------------------------------•----••----------------- I hereby certify that I 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. --- �- ---------IIS- --------------------------------------------------------- { and/or Contractor) (Signed)------------- --- ---- � -- - Owner T By:-.-.. �1-- - --------- -----------------------------------------=----------------rile -,�----- • - �- T� (Plat plan, s awing s 0 ystem in relation to walls, uildings, etc., can be placed on reverse side). FOR DEPAR ENT USE ONLY APPLICATION ACCEPTED BY-:--- -s--I P� o----------- ------------------------------------------------ DATE----------- -- --�ji�--- REVIEWEDBY-----------------------------------------------------------•---------------------------------------------------------------- DATE............................................................ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE----.---------------•---------------------------------------- Alterations and/or recommendations:------------------------------------- ----------..._-----------_--------•--------- -----•------------....•-•-....-------•-------•---------•------------- ----------------•---------------------------------------------- --------•-------------------------------------------------------------------------------------------•---------------------------------•-•------ ---------------------------------------------------•-- ------------------------- ------------------------- ------------------------------------------------••------- -----•-----------------• --. ----------------------- ---------------------------------------------------------- k FINAL INSPECTION BY - -.-----•--- ---------------•-- - --- . �S —e - Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS