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FOR OFFICE USE: s, -- ----------------- - APPLICATION FOR SANITATION PERMIT Permit No. --- -- -------- ---- `S --- -- - -------------------- -- ----------------- (Complete in Duplicate) 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. 549. JOB ADDRESS AN�j LOC/ATI l ',Y,rtee_ 1_ Z! --- --- >v�2aaA ..... � €' 1.: �.4/ ` Owner's Name...... x-_.... . --------•---......-• .._... Phone Address----------- �-•-•-• . . -----•- - 2�a - ....................... Contractor's Name. -- ------------ '•-----•---------------•-•-------- Phone................................... Installation will serve: Residence Apartment House E] Commercial ❑ Trailer,:Court E] Motel E] Other ❑ a Number of living units: _.�___ Number of bedrooms Number aths`_ ___ of size _ _________________ _ ._------------------- Water Supply: Public system ❑ Community system ❑ Private Depthto ater-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 ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No ptic tank or cesspool permitted if public sewer is available within 200 feet.) Q �, f d — Septic nk: Distance from nearest well--__,-.__-._ .Distance fror4pondation-------.i'A______.Material____-__ .__._._.___�-:.__._._.. No. of compartments---- -yam- -_Size_..C.,J.f! XiS-�iquid depth----- ------------Capacity..4; Disposa field: Distance from nearest well.-�0 --._Distance from foundation /�..........Distance to nearest lot li e.�_.__._.... 7�1 Number of lines-----------f-_.------------------Length of each line_____@----------------Width of trench....... .:_-_______________-__ N Type of filter material------- <.__--Depth of filter material_____1.�'____._______Total length-----910_________________________ ge Distance to nearest well____�_e_G'__.-___Distance fr m oundation____l!�.__,_.._.D}stan� to nearest to gine__--______-___-. y Number of pits-.-.-/ _-Linin material....4 :-:_ _.Sizer--.2_X8'_._--___Depth-. __�________________________ 70!/ 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---------- -----• ---------------------------------------------••---•---------------------------------•--------------------------------------- Remodeling and/or repairing (describe):---- --- ---- -----•--•--•-•-•• ---- •-------- ---------------------- o? - - ----- _---------•------ --------- ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ---------------------_---•---------- ---._-.... ----- ------ ---•---------------------------------------------•----------------•-------•---------•-------------•-----------------•-•----------------•--•----------------- I hereby certify tha have r pared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd rule a d r tions of Joaquin Local Health District. (Signed) •-- • --•- A-4-------------------------------------------------------- By: -- ------ pend/or Contractor) By:------------- .................................. -----------�------------- >------------ --�uiildings, ----------------(Title)-------------------------------------------- -- -------------- (Plot plan, showing size of lot, location of system in relation to weetc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 10 APPLICATION ACCEPTED BY---- ----------------------------------------------------- DATE. 7�� REVIEWEDBY---------------------------------------------•------------------ -----. DATE............................................................ BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------- ------ DATE------------------------------------------------------------- Alterations and/or recommendations-----------------------------------------------_---•--------------......---------------------------------------------...-----•------------------------------. ---•-------------••••--•---•-•-•---•-------------••--------•-•--------------------------------------------- --------------------------------------------------------.....---------------------------------------•-•-----•••- --------------------------------------------------------------------------------- ----------------------------•-•---------- ----.._....---------------------......---------------------------- ---- ---------------- --------------------- ---------------------------------------------------------- ---------------------------------- -----------------I----------------------------- -----------------------------------------------------•-------------------------------------.-------------------_ ----------------------------------------------------------- --------•------••----------------------------------------------------------- FINAL INSPECTION BY:..-- ------- ----------- Date 3 �G -•---------------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Noxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CC.