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FOR OFFICE USE: IM, APPLICATION FOR SANITATION PERMIT Permit No. ............... ....... --------------------------------------------------------- - (Complete in Duplicate) - C ------------- --------------- __-._____--.___ `This Permit Expires 1 Year from.Date Issued Date Issued'--_.._-�--.b..6- 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. 544. 2{3 _rgprrfl 1 �. ✓e� sr JOB ADDRESS AND OCA. ION,- �4E _ � - ---- ---------------------------------------- Phone.-...•--------------•--------------- Owner's Name------------ ------ k�-- �- .��_---�.�---• -----....------------------ .� Address--------- - M -��------------------��-�.r�`�`�----------------------------------------------------- �I U---- Phone Contractor's Name______________ ._ Installation will serve: Residence Apartment House ❑Commercial El Trailer Court ❑ Motel El Other L]1� J Number of living units: -J:--- Number of bedrooms _-_--_._ Number of baths _-P3xot size _____ -Z-'2..... t2_jpa- ------- Water Supply: Public system ❑ Community system �-!( Private ❑ Depth to Water Table _._ ____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ . I Previous Application Made: (If yes,date---------.--------..) No New Construction: Yes ❑ NQA SFHA/VA: Yes ❑ TYPE SOF INSTALLATION AD SPECIFICATIONS: � �v T (No septic-tank~ar-cesspoo{permitted-if-public-sewer_.is available-within-200-feet.)- Septic Tank:- Distanc.etrom nearest well-----------------Distance from s foundation--.--__-___----.--.Material-_---______-----_..----.-_--___----._----.-----. No. of compartments-------------------------- depth--------------------------Capacity----------------------- t dl Distancelprom nearest wel I i stance from foundation___0_0----------Distance to nearest lot Number lof lines----------1------------------------Length of each line-------- -__:��..Width of trench....�t��`_--------------- � Type of filter material._ ��` D pth of filter material_____-__--/. X____Total length------ --------------------------- Seepage L n Seepage Pit: Distance to nearest wO---------------__---Distance from foundation-------------------- Distance to nearest lot line----------- L ❑ Number pof pits----------------------Lining material-----------------.---- Size: Diameter------------------------ 9' Cesspool: Distancel�from nearest well----------------- from foundation------------------- Lining material---------------_---___.---- -__--. 4 Size Dia:meter-----------------------------------------Depth---------------- - -------- -----------------Liquid Capacity ---------------------galsIt I _�❑.,ted.... ,�. _ ,a„e...._ „----6 :m: '�,nr i-.�..�tee+- J.Y.•�r-. �r - - -�.-•�: +i �.:�=�.r=r _--..-:s,.----- - -: �_ Privy:.- D�stonce from nearest wel ----------- Distance from nearest building. --------------------------- .. ❑ Distance to nearest lot line-------- ------------------------- - -----------------------------•---------------------------------------------- ------------------------ - Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------- ------------- II --------------- --------- -------- ----- I; ,I I hereby certify that I F aye prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws an Jules and regulation lof the San Joaquin Local Health District. (Signed} '-! ' ' l `'`�' ------ - = -)Owner and/or Contractor) ' f ---r------------ -?:- -------------i--- -- (rtle} ,._:... = i (Plot plan, showing:size of lob, location of.system in relation to wells, buildings, etc., can be placed on reverse side).. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTEDBY---- -------------- ---- ---------------------------------------------------------------- DATE-------------------------------------- --------------------- REVIEWED BY - ----------------------- � DATE — t BUILDING PERMIT ISSUED)�_______________________________.----------- - --- ----- ----- --- DATE-------�------�--------- ------------------•-- -- fAlterations and/or recommendations:-------------- -- ------------- -------------- --------------=-•-----------------------•--=----•-•--------------------•-------------•-----•---•------------ -----------------------•-------•----------------� •-•-------------------------------- ------- -- -------------------------•--•--------- ------------------•-----------•----•------------------------------- ----------------- = -- ---------------- -•-------------------------------------------- ----------------- ------------•----•----------------------------------- = 1 ------------ ---------------------- ;I�' ------ ---- - - ---•------------------------------------- ----------------------- ------------ ------------- ------- - FINALINSPECTION BY:-!----------- ----- -------------- f / Date -------------------------------- - - ------------------------ --------- i . 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 E9 9 REVISED 8.59 31A 3-'63 F.P.CC.