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FOR OFFICE USE: --------------------------------------------------------- -----------------_---------_-------------_-------_--- APPLICATION FOR SANITATION PERMIT Permit No. 11147 . --------------------------------------------------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued 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 Ordinance No. 549. JOB ADDRESS AND LOCATION - /J ` f ----------------------- ! -- - _ -- - ---�- .c`�-�- Owner's Name---- --------- -------------------------------------- Phone------------------------ ----------- Address---------------- ---...---Address------------•----- --------------------- ----- = Phone .._..---------------• --- ------- -�Contractor's Name Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 135 Number of living units: __. Number of bedrooms __"_ Number of bathes-__ Lot size --------------__-.----_-_--_-_----_-_---_-_---___-_-_--_ Water Supply: Public system ❑ Community system ❑ Frivate ❑ 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 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation---------------------Material-------------------------------------------------- El ----_-__________-.__--____-.___-----_. _-_-__.❑ No. of compartments-------------------------Size--------------------------------Liquid depth-------------------------Capacity_-------------------- Dispos Meld: Distance from nearest well_-5f�__1_Distance from foundation-----1C1-- �__--.--Distance to nearest lot line Number of lines____.______- t_______ __________Length of each line--1-V 0........--------Width of trench__ e. ---------------- Type of filter material _ _-1--------Depth of filters material--:.f ----_____._Total length--------lr--C----------------------- yr L lr> -*i' page_. t: Distance to nearest well__�_4�_.-.-k_Distance fr m foundation-_-_IV....._._Distance to nearest lot line__-_��'___: Number of Its___.__- _ �/ y ❑ P ------____--Lining material-____-- 1. ��-_-Size:�r._J�.rt _I Depth----- P-------------------- 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): ____-_-. ----•- -----•-------- --•--•---•---------------------------------------�� -------------------•----------------------------------------------- --- -------- ------------------------------------- --- ------------------------•--------------------------------------•------------------------------•----•--- - -- -------------- ----- --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 5 e ws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- D —is `er and/or Contractor) By �� t _iz� r{� (Title) (Plot plan, showing size of lot, location of system irk relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- DATE � - ----- ---- --------- - - ---------------------- REVIEWEDBY--------------------------------------------- ------------- ------ ----------------------------------------------------------- DATE----- ------------- BUILDING PERMIT ISSUED--------------- ------------------------------------ ----------_---------------•--------------------- DATE------------------------------------------------------------- Alterations and/or recommendations---- -- ------ --- ---------------------------------------------------------------------------------------.-------------------------------------------------- ---------------------------------------------------------------------- ----- ----------------------------------------------------------------------------------------------------------------------------•------------------- ----------------- ---------------- ------------------------•---------------- --------- ---------------------- -------•---------------•----------•-------------•--------------------------------------------------------- ------------------------------------------------------------•-•---------------•------------------------------------------------------------------------------------------------------------------------------------ --------- FINAL INSPECTION BY:.- ------------ Date__._�.� - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 304 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California s E5 7 REVISE0 8-59 3M 3-•63 F.P.CC.