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FOR-OFFUS Permit Na. ____ ... .. _. . V 21_5 ___-----. ------------`------..--_-_------- APPLICATION FOR SANITATION PERMIT ----- - - ---------------------------------------- (Complete in Duplicate) -_-__._------------------- ---------------------------- This Permit Expires l Year_From_Date Issued Date Issued __..__/_7 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 AN LOCATI N 3- -: .. .. f ---• Owner's Name.----- - --------- 214( ---------------------------------------------------------------= ---------•--------•-------------------------------- --- - --- -------------------------------- Phone---...------ ....... Address------------------ -- ----• Contractor's Name.._ _.___ �- Phone.............. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ J Number of living units: ____� Number of bedrooms __3_ Numberlof baths j Lot size ----._.CS_x.A..Z'*..__.___________-__•____--__ 1 Water Supply: Publics stem Communit system ❑ Private Depth Td Water Table �Pft. Y Y Y ❑ P Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loamy E] Adobe g4--HardpanC] Previous Application Made: (If yes,date----------------- No M New Construction: Yes No ❑ FHA/VA: Yes'[] No �� x TYPE OF INSTALLATION AND SPECIFICATIONS: No itank or cesspool permitted if public sewer is available within 200 feet.) SI' lank7ptc � Distance from nearest well_________________Distance from foundation._____________.____Material____________________________-_-.________________- No. of compartments--------------------------Size-----------•------------•-------Liquid depth--------------------------Capacity..._____.--.._.DFiel Distance from nearest well_________________Distance from foundation....................Distance to nearest lot line------------- �Type Number of lines-----------------------------------Length of each line--------_-------............Width of trench--------------•-.-.------.------.-. of filter material-------------------------Depth of filter material-----------------------Total length.......................................... �/11 t r� Seepage Pit: Distance to nearest well ______Distan m foundation-.1p_1--------- to nearest lot line__.-_v bNumber of pits-------1------------Lining materia-__..Size: Diameter---- ._._ ....Depth--.--�� --------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑R . 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):--------------------- --–•-----------------------------------------------------------•---------------•------..._.._-•------------------------------- y --------------••-----------------------------------------------•----...--••-------------------------------------------------------------------------•---------- --------------------------------•----------•-----•----------------------------------------------------•------------------•----------------------------------••----.-.---------•--------•-------------------------- I hereby certify that ! have prepared this applicati n a that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulation$ of S Joaquin ocal Health District. f (Signed)------------------------------------------------------------------------ ---- - ---------- -- ------------------------------------------------------------- By ---------------------------------------•-•---------- --- --(Owner and/or Contractor) BY�----•--•-----•-••-------•---------- ----- --- ----------------- -----------------------------------_1Title).--------- ----------------------------------------------- ---- (Plot plan, showing size of lot, location of system in relation to ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------- •..-•----.. ............................. DATE---------- fes=`.4,,?---------------------.- REVIEWEDBY--•-'-2---------------------- ---------------------------------------------------------------------------------------•-- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED ------------------------------------------- ----------- DATE------------------------------------------- - Alterations and/or recommendations:___! ..-•-•---•---•-----------------------•--------------------------------------- ------------------------------------------------------ ----------------•--------11: ----------------------:----------------------- ------------------------------------------------------------------------------ •--------------------------------------------------------.------------------------------•-------------------------------------------------- ---------------- - ------ -------------- ------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.- ____ ---- ---- - - ----`---.C�.�F�x�.�� Date--------��---'–=-�--�--`--�-'�--- - ------------------------- - : SAN -JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wast 91h Street Stockton,California Lodi,California Manteca,Callfornia Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS Lk