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6OR OFFICE USE: -- ----- ---------------- �,r _ 5 APPLICATION FOR SANITATION PERMIT Permit No. _......... /! .- v in Duplicate) G- ---- "----------- (Complete P 1 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 constWan ' stall the work herein described. This application is made in compliance with County dinan No. 549. JOB ADDRESS AND CA ON....E.r - - - - - • - ------�`----- � ------------------- Owner's Name----------ANDA ------------------------ / - --------------• ---• --------------------------------------------------------------- Phone------------------------------------ Address -------------------"--- •- ------ t 1 --�/ r / Contractor's Name-- ---- -- `!�- ----- f- r ..... Phone--_14__. _- Installation will serve: Residence Apartment House ❑ 70mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ - Number of bedrooms .7'Number of baths __/___- Lot size .-r ---1.Z-- ------------------ Water Supply. Public system [Community system ❑ Private ❑ Depth to Water Table _6dit. _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 2�ardpan ❑ Previous Application Made: (If yes,date.........._.........) No ❑ New Construction: Yes ❑ No UFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ictT nk�: Distance from nearest well-----------------Distance from foundation--------------------Material--_--_______.__----.___.._______-----__-_____. No. of compartments----- --------------------Size----------------------- ------Liquid depth-------------------------.Capacity----------------------- , t o� P Di ;�[� sal field• Distance from nearest well_ *lLa.Distance from founda#ion__�_iP_ .__.Distance to nearest lot line_________________ Number of lines-----I--_____ �_____ Length of each line---�--0.1----�f-Width of Depth of filter material - ._._To#al length____________________ Type of filter material :-_ - — ____ ___ ________ II Seepage Pit: Distance to nearest well-------I-k>w___Distance�yfrom foundation__-, ......Distant a to nearest lot lin �A. Number of pits-_____ _______I_----Lining material__E'C.&C..�`____---Size: Diameter .__.__.-.--_Depth s _�-------------------- 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----------------------- -------------------------------------------------------------------------------------------- -------------------- ''S Remodelingand/or repairing (describe}- ----------------- "---------- -"----- ----------------------------------------------------------"----------- ---------------------"-------•-------- ------------------ ------------------------------------------------------------- '4 - ------------------------------------------ ---------------------------------------------•--•-------------------------------------------------------------- -------- ----------------------------------------- ------ Ihereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin County ordinancl=3-,-State llaws,"andrules and regulations of,the Sa�nJooaqui (Local Health District. (Signed__t`7fJ/ ` ----- �-arid' Contractor) --------- _••�.fgy'��: --•-.--------•----•----------••-•----------------------------------- ---------- - --- --- ----------- ----------(Title--"------"---- ------------- - -"---- -... ---- ---------"---- IPIo't plan_°,showing size of lot, location 64-system in relation t wells, buildings tc., can be placed on reverse side). ( ` FOR DEPARTMENT USE ONLY I APPLIC'A_TION ACCEPTED BY-.!------- ` r'°�'`�----------"------ ---- DATE------"'f�-�� y�� -------- --- ----- REVIEWEDBYti' -" --= ------ ------"---`----- t------------------------ DATE------------------------------------------------------------ ,,._BIJ.ILDING-PERMIT ISSIZI-ED--------------------------------------- -------------------------------------------- DATE - Alterations and/or reco mendations:__.--------------___.._.__-.___� _.-. f -----"---- fit c!' --- ------------------------ ----------- ------- �' ------- `- . -------------------------------------------- .-i � ati FINAL INSPECTION �� -------------- r N BY:. Rate_ --- = _ -----------" " 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 --Eq9 REVISED-a_S9 3M 3-•63 F.P.CD. -^