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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) � y _ 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 Ordina •e No. 549. .. �. . JOB ADDRESS A ' LOBATION_ __ __ - -------------------- ------------------------------- --- - - ---------- --------- Owners Name-- ------------- --- --------- -------------- ---- -•---. Phone .. , .._ - Address____.____/� __:M - 3 Contractors Name------------__ _ ------.-- ...---•--••-----------------r------------------------ ------ - - --------------------------------------i Phone----------------------------------- Installation -:-...-f---------------- --- :--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ______._ umber of bedrooms __ _ Number of baths /_____ Lot size O5'Q _!-_/Z__�_____________________________ Water Supply: Publiclsystem Q/Comrnuriity system❑ Private ❑ '"Depth to Water Table Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Lo;/PNo Clay Loam t3 'Clay ❑ Adobe Hardpan Elrevious Application Made: Yes ❑ • No New Construction: Yes ❑ FHA/VA..Yes ❑ No j TYPE OF INSTALLATION AND SPECIFICATIONS: 7-° (No septic tank or'cesspool permitted,if ublic s wer is available within 200 feetr) t Septic ank: Distance from nearest wel- Distance fro fourtion_�iJ_ at��I,..___________-__._______-_____Q_._ 1 T No. of compartments______ ______ Size_r .. _ - - -•___.Liquididepth_!____ _...-______ Capacity.__ ) ___.__ - -- ��jj - I Dispos 1' Field: Distance from:near}st,w-IYU11 .Distance from foundafion/Q __- Distance to nearest lot lin __l � /� ----•-•-- Number of lines----------- --- Length of each line--------.__ti_-Q Width of trenc>,--- --- -- -,� ` ____. i *.__ i Type of filter materia ' ___ epth of filter material___-___�_ ____.__ otal Iength__R___ Q ________�!_.___. ] Seepa' Pit: Distance to nearest,w i____________•.__ __Distance"rmondt': ante tp nearest lot 12* _,_ yY1.i-~rte/ -------- Number of pits.__:}.�__. _-------Lining materia__ -- -- -DiameterDepth___,___ ________Cesspool: Distance-from nearest well_________________Distanceion._.._.________.____.Lining material____ _..__________________.___._. ❑ . Size: Diameter--------------=----------: - Depth = Liquid Capacity gals. Privy: 'Distance from nearest well-----------------------------------------_--------Distance from nearest building---------------------------- ❑ -Distance'to nearest lot,line-------------------------- `----------------— - - - - ------------ ----------------------- - > Remodfling Ad/or repairing de ribes------- -- ---------------f----------- --=-------------------------=--------------- ---------- ;, --------------- ------------------------------------------------------------ -----------------------------7------------------------------------------------ -. -------------- i _ e 1 ti . ._ J, . # At i �i I _ y 1 ' ------------------------------------------------------------_•--•-=-:--------•------------- ------ --------------------------- I hereby certify that I have-pre d'fhis application and that the work will be done in accordance with'San Joaquin Counfy ordinances, Sta� laws, an rulh nd re lations f the-San Joaquin Local Health District. r c � ' � 1 (Signed) L -------------------------------.-- ------------------------------------- (Owner and/or Contractor) r --------------- --- ( P g - Plof Ian, showing siz� ------------`--------- - ---------------------------------•-------•------•--------- - - -----(Ti#le)------------------------------ ------------- ---------------- kl of lot, location of system in,relation to wells, buildings, etc., can be placed on reverse side). ; 6 FOR DEPARTMENT USE ONLY `+ a APPLICATION 'ACCEPTED BY --------- " DATES------------------- REVIEWED h BY-------------1--- --------- - DATE-- tf\ BUILDINGPERMIT,ISSUED-`--`--------------=----------------- ---------------ii� ------------------•----------------------------- DATE-------W�--------- ----------------------------_------ Alterations and/o recommeations: - --------- - --•--------------------------------------------•--------------.....-.-.-------• --------------- --f t �.' -_----- vZ r�^-0/.6 ae—r��--------��!_�z�------l&LI,t/ �. ' � C NG' LN--.:_ � /, • A$_cn_0_-�----•---•� .-- .... � .. -----P ST -•-=s s6a r------------ !KC,-/aAl�r--------------•- = FINAL INSPECTION BY:---- .... --. Date------------ ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stria} 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M . Reviseci 1-57 FY CO. - .a