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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- J ------------------------------------------------------ -- (Complete in Duplicate) Date Issued ----'_/-x.: 34 -----_____------- _ ------------------------------- This Permit Expires i Year From Date Issued .. — 007 - 32_a_IS- 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 A LOCATIi __ / _ _ ___ /�d' ---- -- ---- -- - --- Owner's Nam -- - ------ Phone----------------------------------- ---------- --- 7-`-- --- ----------- .................... ---------- ----- Contra.ctor's Name _._; f ---- Phone................ . _,._. --•- -•-- ----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: Number of bedrooms .- Number o baths ______ Lot size ___ '" J /---- Number -------------•- 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 ❑ 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 fee+.) t Septic ank: Distance from nearest well--J_D-____Dista cP from joundafii n___-rfl..._.Material--------- _ _�__ �___________________------ -Liquid _____ No. of compartments. ___��.__ --- Size�_�_. Li uid de th_____ _.`_____._____Ca Capacity-- �6Q P q P P y--1-- -------- DispField: Distance from nearest well_-.�b------Distance from foundation----lQ----------Distance to nearest lot`line_._-_____-______ Number of lines_____________/._.__. __-__ Length of each line-----/:(?_Q__ _-__-_._.Width of trench.___,_____,__._ w �� /--------- Type of filter material_____ __��.__�.___Depth of filter materiaL_____�.. ___._ Total length___-_-.-46-C.i______________________ '- ... Seep /eNif: Distance to nearest well--------&Q---___Distance from foundation-------/�O...___.D/i'sta¢n e to nearest lot fine-_�_- Number of pits._______.I-----------Lining material----tS.,t�------Size: Diameter-------4S _.____Dept h___.________________ D Cesspool: Distance from nearest we1L________________Distance from foundation--------------------Lining material-_-__--__._.--._----------.-_________ ❑ Size: Diameter------- -------------------------------Depth------------- -------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----_----------_--------------------------------Distance from nearest bu;lding------------------------------------------ ElDistance to nearest lot line-------------------------------------------- -------------------•--••---------------------------------------------------------------------- Remodeling and/or repairing (describe):1_-_--- _ ' . t ..........------------------------------------------------------S= ---------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------•--------------------=e-------------------------------------------------------------•---------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules and regulations oPtJoaquin Local Health District. (Signed) -- ------. and/or Contractor -------------- --------- By:----------- '-------- ------------- ------------------------=-)Ti+le}_.=-T= r--'- - x f- - (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 APPLICATION ACCEPTED BY DATE,;-Z_V---4----`5-------------------------- REVIEWED BY--------------------------------------------------------------- ------------ ------------------------------------------------ DATE----------------------------------- --- - BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------------------------------------------- Alterations and/or recommendations:------- --------------------------------------------------- -----------•--•----------------------------------------------------•---•-•- ----------------------- FINAL INSPECTION BY: -- = Date_. f ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 911%Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISFR 0-59 3M 3-'63 F•.P.co. -