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FOR OFFICE USE; ------------------------------------------=-- ...... ----------------------------------- -------------- --- APPLICATION FOR SANITATION PERMIT Permit No. .-z,.r ------- ---------- (Complete in Duplicate) Date Issued _- This Permit Expires f 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. i JOB ADDRESS ND TLON , _, --- -------- ----- Owner's -•- Owner's Name-------• --- -- Phone-----•------A------- Address---------' = a li ------------------ ----- I ---- --- ---- -------�----- Contractor's Name--•-•----- ---- - ----------- ------ ----------------------------------- Phone--------------1-----------•------••- Installa}ion will serve: Residence Apartment House ❑ Co mercial ❑ Trailer Court ❑ Motel ❑ Other ❑ J---Number of living units. ___:____ Number of bedrooms __ Number f baths _1-___ Lot size _____ ___ ---------- ______..____._ Water Supply: Public system ❑ Community sys m ❑ Private Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan I], Previous Application Made: (If yes,date_---- ------ --- 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.) 1 -r. Septic Tank: I Distance from nearest well_________________Distance from foundation--------------------Material---------------.--------- ----------------_____El .. No. of compartments............ -- ---- ----Size--------------------------------Liquid de th--------------------------Capacity i Disield: Distance from nearest well_-._Distance from foundation.-_-,1.0-.__-_-- pos FDistance to nearest lot1ine___�---�___- { Number of lines---------- ____ __ Length of each line___:_...Y� ____..j-____.Width of french---- Type of filter material-__. -------Depth of filter material-------4 ___.____Total length_________ _____________________ Seepage Pit:. Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-..- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------- --.-----Depth-_._..__11.----------------------- � q Cesspool: Distance from nearest well_______________Distance from foundation--------------------Lining material--------____________________ ____❑ 1 Size: Diameter----------------------- --------Depth--------- -------------------- ------- -----------.-Liquid EapacitY---------------------------gals. to Privy, Distance from nearest well_______________--___.-___._-___..______________Distance from nearest-building------------------_;---------------------- ?ho El Distance to nearest lot line---- _- ._ '� --- + A - Remodeling and/or repairing (describe):------------- -- ---------------------------------------------- ----------------------- ti ---------- ----------•------------------------------------------------------ ---- ----- ---------'-------------------------------------------------=------=--- -- - ---------------------------- ---------- -------------------------------------------------------=------------------•-••------------ ' I hereby ce ' y t I have prepared this ap licaf ion and that the work will be,done in accordance with San Joaquin County ordinances, St a law , nd rules and regula 'ons o the San Joaquin Local Health District. { (Signed)------ -•---------;- •-•----------.-•-•• ••- --- -------- - -------------------------- ------ -- ------------------ ki -and or Contractor)` ... r ,$ `BY•--------- -------------- --- --------------- - - - ----------------• --•---•----{TttleJ ••----- ------- ,--=---_------------ (Plot plan, sho size of to}, location of system in relatio o wells, buildings, etc.,can be,.placed,on reverse side]. f FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY/,Z --- ----------------------------------------- DATE-- /-------- v--"G-- REVIEWEDBY--------------------------------- ----------------------------=--------------------------- DATE------------------------------------ ------ BUILDINGPERMIT ISSUED----------------------•-•--------------------•----------------------------------------------------._. DATE-------- ---------------------------- ---------------- '� _ -.._ �.,.._T ...-M.... �._ Alterations and/or recommendations:................... . "` "- "-- ' - -- -----------=------ - ---•---------- --••--------------•----------------------------------- - . . t -----------------------------------------------------------"�. ---------------------------------------- ------------------------------------•-------------------------------- -------------- ---- ----------------------- ----------•-•--•---------------- 1 FINAL INSPECTION BY:. r2W ---------------------- Date-- - --------------------------------- i I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 0-59 3M 3-'63 F.P.CC. 'ts a