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FOR OFFICE USE: --------------------V1--------------------- APPLICATION FOR SANITATION PERMIT Permit No. -------------- ---- -- - -------- -- ---- - ---- --- -- - - ;<..-k... ` } 'i- - -- - ------ ---- -Q (Complete in Duplicate) Date Issued --------- - i _... --- U,-------------------------------- 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. 9. -.__ JOB ADDRESS AND IOC TION--------�__ _.�_.:.r � -�=�J. ------------- ------ Owner's Name. f Lam = Phone------------------------------------ Address-----------•---------= ------ --- - -- - �. � } fY' z" Contractor's Name--- -__�-/�-}'_�==�--•�-I i --------------------------------- Phone------------------------ Installation will serve: Residence [A� �Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___,_. Number of bedrooms.. Number of baths Lot size __._�,,}__._.___�__1_J__—v_ ------------- Wafer Supply: Public system Z--c7o-mmunity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ej---h'iardpan ❑ Previous Application Made: (If yes,date._------- --- -----I No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S 'c Ta k: — istance from nearest well.................Distance from foundation-----.-----_--- Material------------------------------------------------- 1 No. of compartments---- _-Size--------------------------------Liquid dep�h------------- ------------Capacity----------------------✓ po field: Distance from neares well t-k.Ql�... isfance from foundation----l ----....Distance to nearest lot line------- -- Number of lines.__,.__ Len th of each line_s_" r_ Width of trench_._ --i�r4& __ - } - if 00 C� �� Type of filter material. 0epth of filter material--_.---- -_(--r Total length-____.._._____ _ _.�.,.�__ l{Seepage Pit: Distance to nearest well._ - -_-Distance from foundation------/ Distance to nearest lot line...... ....... )41 Number of pits,---I-----------------Lining mate ria l__� t:<__ .Size: Diameter._- _- 'IDepth. Cesspool: Distance from nearest well____-_-_._.----_Distance from�o_--u-n--claf ion____________________Lining material_ _.____..._.__.________._._______-_ ❑ Size: Liarn0er-------- ------------ - -------....De th-.-------. - . _ ------- � -- ..- --------Liquid Capacity_ -------- -- ---------gals. Privy: Distance from nearest well---_---------------------------------------------Distance from nearest building_._.__.______.__________-_ ❑ Distance to nearest lot line- - ----- -- - -- - ------- ---------------------- ---- --- . . --------------- 00 11 Remodeling and/or repairing [describe]:___...._ ------ ---.- Vt ------------------------------------------------------------------ -------------------------------------------- ................... --------- - -------- ......... --------- ---- -- --------- ------ 3 ------------------- ------------------------------------ --- - . - -------------------------------------------------------------- ---------- �- / ? ------ :L r - ----------------------------- ---- - - I hereby certify that I have prepared this applicationtcand that the ork will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-----JL------6-&, ..... L� .lc. �? • �� ------ ----------------------- e d f-Contractor f !� Title (Plot plan, showing size of lot, location of system in relation to ells, buildings, e/C., can be placed on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY------------- = --- ----- ---------------- DATE------. = = `----------------- REVIEWEDBY----- ----------- - --- ...... - --------- -------------------------------- DATE----- ----- _-------------------------------------------- BUILDINGPERMIT ISSUED------------------------------- ---------- --- ------------ ------------------------------------- DATE----------------------------- ----- ---- ----------------- Alterations andIor recommen ations: -------- --- - ----------------------- ----I--------------------------------------------------------------- - -- - _ -------------------- ......... ] -- ----------------------------- ----------- ------------ --------------- --------- - -- - ---------- - -- ---_--_-r----------------------------------- -------...---------------------------------- - --------------------------------------- --- --- - -------- ' Gam: FINAL INSPECTION BY:..............`-- c. Date--- J_ --- ---------------------------- ------- SAN --- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVISED B-59 3M 3-'63 F.p.CD.