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FOR OFFICE USE: -a -------- -------- ---- ---••----- APPLICATION FOR SANITATION PERMIT Permit No. .. ..:. --------------------------------------------------------- (Complete in Duplicate) f 2 Date Issued .__.......� _.�_ ___________________--.______.__--___-.__,__...______ 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 49. JOB ADDRESS AND,L CATIOta `(X�.( - --- . . -- -- -----------•------------ Owner's Name 11--�� L-� � -------------------------- Phone. Address f l� ----------- ------ �-- ----`�; Contractor's Name----------------- -•--- / t-----...- --- ------------------------------------------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑f Motel ❑ Other ❑ Number of living units:/_�___ Number of bedrooms__.-?�'-Number of baths --- Lot size ---------------------------------- Water -- __ #i Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. .<y 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 E] New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No ptic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well..__-------------Distan e from foun�tion-----�--�-------Mte ial----- ----"-----•-.----........... No. of com artry�ents_.___I'-. _ ,�t�EA,-/��r f P ------Size-1 fF 7--<!-•-----Liquid depth Capacity./� ®d Dispo Field: Distance from nearest well XO___.._Distance from foundation.. Q___....___Qistance to nearest lot line,... __..... JI Number of lines__......../__.___ _ Length of each line__„ 11------------ Width of trench :___P--- ----------------- _ Type of filter material_._ _. t-----Depth of filter material___--__-/. __Total length.---------X-4_ _ ____________/-__._ Seepa Pit: Distance to nearest well____r"©a.�.Distance from founda 'on____.__L 8-�-.Distance to nearest lot line-5, Number of pits------ -----Lining material-- --___.-- D,i•�er�;K"1 A5epth-----/.G--------------------- Cesspool: Distance from nearest *ell-----------------Distance from foundation..------------------Lining material_--..-----_-__-_---.___.._..._--____-. ❑ Size:,Diameter.,.....-.41— ---------------- Depth------------_-_- --------------------•-•--------Liquid Capacity---- ----------------------gals. Privy: Distance from nearest well---.----------------------------_----------------Distance from nearest building----------------------------.------------ Di nce ___-__. __.Distance to nearest lot line------------------------------------------------------------------------------------------- ----------------------------------------------- R a --•-------•--------------------Re deling and/or repairing air�ing_P(describe) - . �....--• -- r -- � -- . t ----- I hereby certify fhat I have prepe'red this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and_v4s and regulations of the San Joaquin local Health District. (Signed) -- ------ -- - - d/or Contractor) r, ------ By:................. ' ... ------ T'itle)--------------------------------------- -- --- ------------- (Plot plan, showing size-of lot, location of system in rela}ion to wells, bui gs, etc., can be placed on reverse side). FOR DEPARIENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------ DATE.- 'c72.z - ----------------------------------- REVIEWED - --------------------------REVIEWED BY------------------------------------------------------------------------------------------------------------------------- -- DATE-------------------------------------•---------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ------ DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------- --------------------------------------------•-.. --------••- -•----------.... ._.......................................... -------------------------------------------------------•-•-------------....--------•----------•----••-•--------------------•---------------------------------•--------------------------------------------------------.....-- ---•----------•---------------------------- --------------------------------------------------------------------------------- ---------------------------------------------------------------------_------------- ----•-- --------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY:-._.11�a .a_,° pt- -------------- Date----7 --. °_Z'----wl5r--- ------------ 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 ES 9 REVISED 5-59 3M 3-'63 F.P.CD. iV