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FOR OFFICE USE: t ---------- --------:--- - ------------------------------- �--� -------------------------- _------ APPLICATION' FOR SANITATION PERMIT Permit No. ----------------------- -------------------- --- ------------------ ----- (Complete in Duplicate) Date Issued ______7_l � ----------------------_.___._.-..-----_.-..____..__-.__- This Permit Expires 1 Year From Date Issued_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrl d. yj This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION!--?,#ZL&A�-t __ �-- _l2-___ Gt r'rrna�__ ___�— - -- --- —~ n OwnersName ------------- -------------------------------------- Phone /� ?6 ------------------------------ - -- Address -- --------------------- Contractor's Name-- '/' ------------- --------------------------•----------------------•------------- Phone----------------------------------- Installation will serve: Residence �Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units- I---- Number of bedrooms __._ Number of baths _I----- Lot size --- _ _ __________-____---_.__ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table--------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Z Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date- ---------_..__.-) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE:OF INSTALLATION AND SPECIFICATIONS: y (No septic tank or cesspool permitted if-public"sewer is available within 200 feet.) c :� Septic Tank: Distance from nearest well---------- ''Distan'Ife from foundation -------------------Material----.---____-__-_____..___.__________-_...._____. ❑ No. of compartments- -------------------- Size-- ------------------------ ---Liquid depth----------------- --------Capacity---`-------•----------- Disposa field: Distance from nearest well_.! ..._____Distance from foundation___._ ?.---------Distance to nearest lot line___ Number of lines______-__/-------------- -----j_'Length of each line------�:G0_-_�«-----Width of trench------2�----------------.--•- Type of filter material - tDepth of filter material ._,L- _-_______.Total length-------� _d- ________________ JT Distance to nearest well-=:__f_ !'�__-____Distance from foundation---._ stance to nearesf lot-line-------.___._ Number of pits,----/-------------Lining material-----Size: 4 taTa erxr --- � Depth------1 - ---f---.-- Cesspooi: Distance from nearest we'll-----------------Distance from foundation--------------------Lining material------__.___-_----_-- Size::Diameter "` Depth- x---------------` G ❑ S p Liquid Capacity--------- -------------gals. �. Privy: Distance from nearest well---------------------------------- , --------Distance from nearest building-------------- R--______ ._-_..___.._. i ❑ D'stance to nearest lot line--------- - -- -------------------------------------------------------------------------------------------------° ------ ------- .01 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, St laws, and rules and regulations of the San Joaquin Local Health District. - (Signed) = - -------- - - ------------ --------=------------------------------------ ---------- -- ner and/or Contractor( By e`k -=- _ �_ ---------- --- --------------------------------- - : (Title)_ =�- (Plot plan, showing size of lot, location of system in re tion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -------------------------------------------------------------- DATE---- .----------- REVIEWEDBY-------------------------------------------------------------------------------------------------------- --------------------- DATE-------- --------------------------------- ---------------- BUILDINGPERMIT ISSUED--------------------------------------- -------------------------------------------------------------• DATE------------------------------------------------------------- Alterationsand/or recommendations:------------------------------------------------------ ---------------------------------------•--------------------------------------------------------------- -------•-------------------•-------------------------------- -- ----------------------------------------------------- ----------------------------------------------------------------------------- ---------- --------------------------------------------------------------------------------- --------------------------------------------------------:----------------------------------------------------- -------------------- ._._.-- ------ -- -------------------------•----------- ------------------- ----------------------------------------------- ----- w FINAL INSPECTION ___.__.__------ ---- date---. _�_" -+ - --------------------------- ------------------ SAN JOAQUIN LOCAL HEALTH -DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Marntecar California Tracy,California CS 9 REVISED 6-59 3M 3-'63 r.P.Ga.