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FOR OFFICE USE: ),L r /Y ---- ----------- ------------ -------------------------- 'APPLICATiON FOR SANITATION PERMIT Permit No. .r !1I-- � ------------------------------------------ ---=------- -- (Complete in Duplicate) This permit Expires 1 Year From Date Issued Date Issued A lication is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. pp Y q This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION �A._yh-_-,i/-------� ............ ------------------------------- r . Owner's Name-- ----� --• � --- -- - ------------ - ------ -• Phone--- Address...............----If?11.0F.... -•-•- :-�"_�.tr'-�-----------------------•----------------- ---•------------------....------------•---•-•------ - - ------•-------------- ---...._._ -• - Contractor's Name__• __- :--------------------------- --- Phone..................•---------------- + Installation will serve: Residence Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1---- Number of bedrooms _ _._ Number of baths I------ Lot size 11.____----- hAly.-_-_-_------------------ ---- Water Supply: Public system El Community system El Private ❑ Depth to Water Tablebp--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam'Dd Clay ❑ . Adobe E� Hardpan ❑ Previous Application Made: (If yes,date--------------------1 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.) J Septic Tank: Distance from nearest well------- -------Distance from foundation-------------------.Material---------------------------.----------.---._----- ❑ No. of compartments------- ----- ------------Size----------------------------:---Liquid depth------- ---.-.Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of lines-----------------------------------Length of each Iine------------------------------Width of trench----------------------------------- Type of fiiter material-------------------------Depth of filter material ...-------------------Total length------------------------------------------ Seepage --.-__-----__ _-----__-----_----__--._Seepage Pit: Distance to nearest welf �_�..____Distance from foundation__ .a---------_ Distance to nearest lot line_r7___a_.__._ ` ,.< � � � _ �, , Number of pits---- --------- ning material__/l - -- ---Size: Diameter.--- -----.------_Dep+4.4..__....--_------------.-- Cesspoo#: Distance from nearest well-----------------Distance from foundafiion--------------------Lining material--_-_..._--._-_-..--.-.---_._----_-. ❑ Size: Diameter-----=-------------------------------Depth--------------------------- --- - -------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_.----_-.----.---_-__---_-_-------_. ❑ K Distance to nearest lot,line--------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe) =------------------------------------ ------------------------------------ ----------------------------------------------------------------------------- x 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ` ordinances, State laws, and rules and'i're tions of the San Joaquin Local Health District. (Signed) -------------------------------------------------------------(Owner and/or Contractor) By---------------- ---(Title)----------------- ----------------------------------------------- (Plot -----..-..----------- ---- -- ------ -- --(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY y APPLICATION ACCEPTED BY. --------------------------------------------------------------- DATE___`- _'6_4(_-___-------------------------- -- REVIEWED BY------- ------------------------------------- -------------------------------------------------------------------------------- DATE--------------------------------------- --- -------------- BUILDING PERMIT ISSUED------------------------------------ - DATE --------------------- ---------------------- Alterations ------ --------------Alterations and/or recommendations--=------------------ - ------ - ------------ ------------------------------------------------ --------------------------------------- ------------------- ----- ----------------- -------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------- ------------ a FINAL INSPECTION BY:`. .. ----------- Date---- --------------------------------------------- SANOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,Calif rnia Manteca,California Tracy,California } F.P. p. .4