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FOR OFFICE USE: r Permit No. ___ -.�•-- •--- �1 APPLICATION FOR SANITATION PERMIT �= = --- --------- ��,/ t. ---------------------- ---- - _ � (Complete iri Duplicated - ' �' Date Issued ----•-------•--=--�''--. ----------------------------- -------- ------------- ------------ This Permit Expires 1 Year From Date Issued pp--- A Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in compliance with County Ordinance No. 549. d ----------------•---- -------•-- ---- 1 JOB ADDRESS A �Tl��--LOCATION_. --- ~ on Ph - � .----0,�-- - -------------------- _... Owners Name______- _ C _ _ ------------------------------------------------ Ph Contractor's Name -----------•-----------------•----- installation will serve: Residence 0 Apartment House El Commercial E] Trailer Court ❑ Mote ❑ Other __________ Number of living units: -------- Number of bedrooms __'- Number of baths _ -- Lot size ------------------------------ ------------- Water Supply: Public system ❑ Community system ❑ Private-�epth to Water Table - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay . Adobe Hardpan ❑ i 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 ZOQ feet.) Septic Tank: 1 Distance from nearest well________________'Distance from foundation-------------------Material___--...____---______._.------------------------ i ❑ /�'' No. of compartments---------------------------Size_--------- ---------------------Liquid depth--------------- --------- Capacity Disposal Field: Distance from nearest well__ -.Distance from foundation,-"� a_.______-_.Distance to nearest lot line_._.__ 1 -� umber of lines__.___�____- Length of each line__h-- - ---------Width of tre ------ ___.-____ 71 -------------Total length- ype of filter. materia`I___1.d-+ �C----------Depth of filter material_ _ __I-- 9 Distance to nearest lot line -------- rest s I See if: Distance fo nearest welly----- ---Distance from foundation__-----------_. �e th ---7-, S g /r .Size: Diameter--- - - `� P ti Number of pits-----1-------.- --- Lining matenal�-/�Ll_-- -- ing Cesspool: Distance from nearest well-______---------Distance from foundation__.---------------L�nuid Cateacit gals. Depth------------------ ------------------------------ q Capacity ❑ � Size: Diameter-------------------------------------- Privy: Distance from nearest well---------------------- - .__Distance-from nearest building----------------------------------------- - ❑ Distance to nearest lot Iiine----------_______----------------------- Remodeling and/or repairing (describe):____"_.__.__-.-T.------- ; = ------------------------------------------------------- ., ------------------------------- ---- ti ------ ------------------------------------ I Hereby certify that I have prepare mats ns olf the San JoaquinhLocalkHeal heDistr done in accordance with San Joaquin County ordinances, State laws, and rules "---__.___--"________________{Owner and/or Contractor) (Signed ------- --- ------------ ------------- ------- ----------------------- - ---------- -- - -- ----------------- -� -- a ----- ------ 1 ay.- of sysfem in relation to wells, buildings, etc., can be placed on reverse side). i (plot plan, showing size of lot, r FOR DEPARTMENT USE ONLY 4-11 APPLICATION ACCEPTED BY______.- ___.___-.-. -- - DATE-------- � � ' ------ ----. DATE- -- ------• -- ----------------------------------------- I REVIEWED BY----------------------------------------------------------- ------------------------------- ------------------------ -------- ---------- --------------- - DATE------------------------ --------------------------- ,..�: -:----- ---------------_---- BUILDING PERMIT- ISSUED- - ---------------------- --- ------------------------------ -----------------------r Alterations apd/or„recommendations:------- '-- --------- c�C —. = ----------------- ----------------------------------- -------------- ---------- --------- ---------------------•------- --------- --------------•-------------"----------------------•----------•--- - --••------- ---------•----------- - - 1 __________________ ___ ___ y, IX-t / 4 ZI /-- '' C. Date------- --------•- -. --------- ---------------•- FINAL INSPECTION BY:_..------` (------- --------------------- t � SAN JOAQUIN LOCAL HEALTH DISTRICT 300 west oak Street 124 Sycamore Street 205 West 9th Street i 1601 E.Haielton Ave. a Lodi,California Manteca,California Tracy,California Stockton,California , E5 9 REVISEo B-59 3M 3-'63 F.P.CO.