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FOR/OFFFIICE USE: t� Ir ------------------ ---------------------------------- \APPLICATION FOR SANITATION PERMIT Permit No. �Z.L. - (Complete in Duplicate) t ----------------- I This Permit Expires 1 Year From Date Issued 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 AND LOCATION---------�-'7--Y -------- ; / �•,�C_f" <cu-� � Owner's Name.- t..... � - Phone__—V2,7................/•3 Address ---- ------ --------- - / F Contractor's Name----------------------------- - Phone_'t �!�-.'_. ��0 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ x' Number of living units: ,`._._ Number of bedrooms ,3 Number of baths __ _ Lot size 1 ---------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table,5:!?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 ❑ NoX FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pti Tank: Distance from nearest well_________________Distance from foundation--------------------Material____----_-_----:_•---_--__--_---___--__.___.____. • No. of compartments--------------------------Size-------------------------------Liquid depth--------------------------Capacity------ ----------- �eld: Distance from nearest well-----------------Distance from foundation....................Distance to nearest lot line................. Number of lines___________________________________Length of each line------------------------------Width of french----------------------------------- Type of filter material---------------_---------Depth of filter material-----------------------Total length------------------------ 4Distance to nearest well_/0_Q___--.__Distance fr m fo ndation,�Q_..._..__.Distanc�ep to nearest lot line---- [�-''`^ Number of pits__._._____________Lining material__ ___ ___Size: Diameter____�0..._____Depth----- ............... Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- r ❑ Size: Diameter----------------------•-- ---------.Depth---------------------------------- Liquid Capacity gals. Privy: Distance from nearest well------_----------------------------_-------------Distance from nearest building-------.------------._-_-_-_-.____---_-._. ❑ Distance to nearest lot line-- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- --- -- - ------- --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances a e laws, an rules and regulations of the San Joaquin Local Health District. (Signed)------ - . -- ---_... -- ------------- -------- -------- r ----------------------- Owner and/or Contractor) By: ------- - S-"",�------- -(Title)---C_-------------------- ----- -- ---- --------- (Plot plan, showing size of lot, location of system in relation to wells, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ .__-_____.__ ,_ - _ - - 2 -------------- DATE----` REVIEWED BY--------------------------------------------- -------------I DATE BUILDING PERMIT ISSUED------- -- ----------- . 11------------ DATE----------------------- ---------------------�------ Alterations and/or recommendations:___.__ _ ��1� � ---- ----- }-----��-z -- ---------_---- -------------- ---------- ---------------------------------------------------------- ------------------------------------------------------------------------------- --------------------------------------------------- ------ ----------------- ------- ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- ----------------------- ---- 4 �_ FINAL INSPECTION BY:. / ------" ------------------------- Date---------� -- 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 S-S9 3M 3-'63 F.P.CD.