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FOR OFFICE USE: ` ----------------------------------- -------------- APPLICATION FOR SANITATION PERMIT Permit No. 22 ------------------------------------------------------ (Complete in Duplicate) Date Issued -._----------------_----------------.-------------------- I This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. Pa JOB ADDRESS AND LOCATION...........�or _ Q01 ___i�.``................ ........ ._ -._---- � ry ��p` kU ------------••-- t�_ Owner's Name---------------------.&)DR�....__l_00� ..---.J��- ------------------------------------------ Phone -- Address.................... ----Q........g "...Al�..-----------•---------------------------------------- Contractor's Name----Clow- ------------------------------------------------------------------------------------------------------------------------ Phone................................... Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... Number of bedrooms ---I--- Number of baths ---/... Lot size ______ -_ _----•___________________________ Water Supply: Public system ❑ Community system [ Private ❑ Depth to Water Table __/Q 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 0" New Construction: Yes [2"No E] -- FHA/VA: Yes ❑ No 2 TYPE OF INSTALLATION AND SPECIFICATIONS: /7vve ZA (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-1W.-e-----Distance from foundation----/P___........Material...___l�hh ►�t�------------------------------ .0 �'________________________ � [� No. of compartments___.-___-o.2_____________Size_ _`.....__. ?,®_,__.Liquid depth____--_`__..____.__._Capacity... �o DisposaField: Distance from nearest well_PQ4_2....Distance from foundation... ®_________.Distance to nearest lote.... .__...... Number of lines_____________ 0°1_____-_________Length of each line_._______' 4'-_-______-__._.Width of trench..__.__ ....... Seepage Pit: Distance to nearest well______________________Distance from foundation....................Distance to nearest lot line_.._-_____--___-• � ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------------.--------Depth-------------------------•-----.- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth---------------------------------------•--------_Liquid Capacity----------------------------gals. Privy: Distance from nearest well _-_______________-----------------------------Distance from nearest building______________________________________--_ ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------------•-------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------•-------------------•-•----------------------------------------------------------- a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County \ ordinances, State w and rules and regula 'ons of the an Joaquin Local Health District. (Signed)..)( _.._.___-(Owner and/or Contractor) By:------------------------------------- - --------•-----•-•---------- - -------------------------------------------------------(Title)-------------------------------------------- ---------------- (Plot plan, showing size of lot cation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ---------- ----------------------------------------------------------DATE--------' ��= ;2 APPLICATION 6 REVIEWEDBY-------------------• ------- ---------------------------------------- --- DATE------------------------------------------------------------ BUILDINGPERMIT ISSU ------------------------------------------------------------•--------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------------ --------------------------------------------------------•---------------------------------------------------- ----------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------ ------------------------------------------- FINAL INSPECTION B .._' ;> ' �--- - ----- - - - ------ ---------• Date-----------��_----=D/ ----- ----------------------------------- ( AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California __ Lodi,Californla Manteca,California Tracy,California Es 9 ttf<WS&D 8-59 3M 3-'63 F.P.ED. --_,