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FOR OFFICE USE: ------------------ ------------------------------------ -------------------- -- -------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ..... --------------------------------------------------------- (Complete in Duplicate) Date Issued _-- -- --- _ This Permit Expires 1 Year From Date Issued _�_�:�----- -------------------- C' (S'O �-d � Applica#ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here'j�Ra,,d�escribed. This .application is made.in,compliance with County Ordinance No. 549. I'7 �3w7 � JOS ADDRESS A LOCATION �� sc/_ I - __�'� _-C`t ` - 4' J-s�k,� 1^►�s - -` "` -- _� = g . Owner's Name-----_�'�_-5Z�__. /6-----•- 9 `' � - --=---------- Address---- ---=:3--'7_-_--.----•----------------- -� f ----------- •----------------------------------- --------------------- /� ° E •. Contractors Name P.. �re 4,.�_;,oe, ----------------- Phone----•-----------•---•---- Installation will serve: Residence Ir Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____/__ Number of bedrooms _:_ Number baths _1__-- Lot size _______ ___ Water Supply Public system El Community system ❑ Private De;?,C"Iay Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:: lif yes date_______________-- -) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ f 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--------------------------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity----•---------8------- , Dis osa field: Distance from nearest well-__4' (____.Distance from foundation___.. P'_-r_....-.Distance to nearest lot line.____.__ ! g�l P Number of iines______I___�__t__�__ _ Length of each line___-�-_Q-�--!____..______Width of french.---`�-____._______.________dQ Type of filter material__t"!-------------Depth of filter material------ ____.-_.-Total length---.....j__t__0-------------_--------- 444_62T- Distance to nearest well-----1�6-f-----Distance fr9)m foundation____!._----------Dist ance to nearest lot line___`----_-- ❑ Number of Pit Depth ..s- ----�-- --------- Linin9material � -------- � = Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__________________-------__--_-_____ ❑ Size: Diameter-----------X-------------------------Depth--------------------------------- -----------------Liquid Capacity- ---------------------------gals. Privy: Distance from nearest well---------- ___________________________Distance from nearest building----------------------------- --------_-V El Distance to nearest lot line------------------- ----------------- Remodeling and/or repairing (describe): - = ----------`-----------=----•------•------------------------------------------------------------•--------------- -=--------•-- --•------------------•-------------------------- -------------------- - --- - ------- ------4-----•------------------------------------------------ ------------------------------•----------------�----- r ------------------------------------------------------ ----------------•---•--- ---------------------------••�-:---------------.------------------------------------------------------------------------=-------'------ --------------------------------------------------------=----i-•----------••-=------------•--•---------------------------•r------------------•____--------'---------__-----------------------------'----------------------- ! hereby certif, that I have prepared this application and that the work will be done in accordance with San JoaquiWCounty� ordinances, State aw , and rules and regulati,o f the San Joaquin Local Health District. J. A _ (Signe0 d) r ----------------------------------------- --------------- and/or Contractor , ---------- By:, ••--• t ----------(Title)------------------------------ -------- --------- (Plot plan, showing size of lot, location of syste+ in relation f wells, buildings, etc., can be placed on reverse side). `�✓ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- ------------ ------------------------- DATE----- -------- - -'------------ REVIEWED BY-------------------------------_ --------------------- ------ --------------------- -- ---------------------------------- .. DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------- --=-- ----------- €--- --------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------- -j ------------ - ----------------------------------------------------------- •-------------------------•-•----•---•-=-------.------------- 1 9i , ---------------=-----i-----------•. --�------- --------- s F t if 1 .F 3 �- �. ---.-- -- --- - -- - ------------ --------- -------------------------------------- - ---------- -•------------r------..- ------•------------------ -- -- FINAL INSPECTION BY:.-'1:::4_1 ----------------- =• Date - - ------- ---- -- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hatetton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street - Stockton,Californfa Lodi,California Manteca,California Tracy,California E6 9 REVISED 8-59 3M 3-'63 F.P.CO.