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FOR OFFICE USE: "a'. --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------- ------ ------------------------ (Complete in Duplicate) (p ------------------ This Permit Expires 1 Year From Date Issued � Date Issued _______ Application is hereby made to the San Joaquin Local Health District for permit to _ / l CJ— pp y q p construct and inst`a�l the pork here described. This application is made in compliance with County Ordinance No. 549. J� ADDRESS A LOCATIO .. _ __ -------- 4P s-•c 1f4�I I �'"hLa___ Owner's Na ----._.. .__� --- -- - -------•--•--•- ��t ,. � Phone------------------------ s , Address__iF" - ------------ - ----------------------------------------------------- ------------ ---_-------------------- Confra&or's ..... Contra&tor's Name- -- - ------ ------•---- ---------------------------•---- ----------------- Phone......... --------- k Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __!____ Number of bedrooms .-7--'Number f baths __f____ Lot size _ !. .___ .__. ---------------------- Water Supply: Public system E] Community system E:1Private Depth to Water 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 septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-_-_---------------.Material--.._._.....-_---_.-_-_-_----_----.----_-_-_----- ❑ No. of compartments------- --- -------------Size-----•-------------------------Liquid depth--------------------------Capacity------------- ------- Dispos field: Distance from nearest welL__* + .�_._Distance from foundation=__JC_:_I>_-----Distance to nearest log Number of lines-----------II- Length of each line-----. ----------------Width of trench_.__ -_----------------------- f_ ---------- Type of filter material, >� epth of filter material------ __ Total length______,' ___________________________ �1 Seepage eepag it: Distance to nearest welt------A0------- Distance�,fo� (ffoundation--_-_-i4_____..Distance to nearest lot lin Number of pits---------I-----------Lining material_461=_ `--..Size: Diameter--------}.�_...___Deptn.-.`.._rC_....................._ Cesspool: Distance from nearest well-----------------Distance from foundation-----_{------------ Lining material_----.-_-------.__.-_------_--._-----. ❑ Size: Diameter-----------------------•--------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. - Privy: Distance from nearest well-------------------------------- -----Distant a from nearest building----.--------._---_--_---__---._---_-_--- i ❑ Distance to nearest lot line------ ----------------------------------------------- ------------------------------------------------------------------------------_- i Remodeling and/or repairing [describe]:___________________________'_ ------ ------------- o �' - 'sw� ---- - -----------------------------------------------------------•-------------------- -------- ------ -- -- -------------------------------- y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules nd regulations of the San Joaquin Local.Health District. (signed) i - ------------ {Owner and/or Contractor) ---- t<••----�- ; - -------- By: _ : (Title) (Plot plan, showing size of lot,.location of system in rel ito wells, buildings, etc., can be placed on reverse side). FOR RRtDEPARTMENT USE ONLY APPLICATION ACCEPTED ---------------------------------------------------------- DATE--- -k-l3--4-3---------------- ----------- - REVIEWED BY------------------------------------------------- ---------------- - ------------ -------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------•----------- ------ DATE--------------------------------------------- ---------•----- Alterations and/or recommendations------- ----------- ------ ------------- ----- ------------------------------------------ .............................. ..---------------------------- -----------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- ------------- ----------------- ------- ---- FINAL INSPECTION BY:-e1,�9- ----------------------- Date -�a �� G --------------------- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ka:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD. 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