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FOR OFFICE USE: -------------------=------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ----!�-__--..d. --------I--- --- ---- ----------------- --------------- (Complete in Duplicate) Date This Permit Expires 1 Year From Date Issued Qa+e Issued `�"� t 1___ �} Application is hereby made to the San Joaquin Local Health District for a permit to-construct and install the work h in cribed. This application is made in compliance with County Ordinance No. 549. LOCATIO JOB ADDRESS -;..... Q-1 Owner's Nam �^ # '. -------------------- Phone----••-----•---------------------- � Address--------- ---- r -- ----- --------------- ---------- ----------------------------------------- Contractor's Name - �, „----------- ------------ Phone.------•-------•-------------------} Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ Number of bedrooms y-__._ Number baths -f----- Lot size Water Supply: Public system ❑ Community system❑ Private Depth Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] 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.) I Septic Tank: Distance from nearest well_______________Distance from foundation--------------------Material-------------------------------- ---.________- No. of compartments--------------------------Size---------------------------- ---Liuid depth--------------- ------Capacity Dist Dispa Field: Number ofolinesearest well_�0__�...Distance of each line_ation.;�4 -r- W��thcofttre chnearest I�ot li s---=-------------. 1 -_Total length-------- -- e ------- --- ---ice Type of filter material-____ �-�__Depth of filter material_______ _ - �g , Seepage Pit: Distance to nearest well _______________Distance from foundation-------------------.Distance to nearest lot line___-______..___._3 I ❑ Number of pits-------------------------Lining material-----------------------Size: Diameter-------------_.-.------Depth------.__.----------------.------ Cesspool: Distance from nearest well-----------------Distance from foundation--------x_---------Lining material________________------------------------------------- N _,r,_0...__.,.,_Size:_D.iameter.------------------------------------=-Depth------------�---------------------- ti-- -�-----Liquid Capacity-------- Privy: Distance from nearest well_____________ ---------------------=___ _Distance from nearest building___._________________________._____.._. ❑ L ° t Distance to nearest lot line:`"p ------------------------------------------------------------= .. ._ ------ ----------- - + r .�.�,_-'�""'- —�•�-..�,.e.,.n..-.,-../_.�-.,...,.....i...��.,w.�._.,_`�.. -- .w.�..� �..:,�..•,....�.,:.y:.-_„ X11—.� � � �4.rwe..ti, mow`. Remodeling and/or repairing (descriU ----------------------I-------------------------------•------------------------------- -- 9+ --------------------------------------------------------------------------------------------------------------------------------------------- - - ----------- --------------•-------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la and rules and regulations of the San Joaquin Lccal-Health District. I (Signed( --- -- 0 = €; nd/or Contractor) BY•--•------------- (Title) I (Plot plan, showing size of lot, location--of system in relation to well buildings, etc., can be placed on.reverse side). �., v i c ii I ,) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------------------------- DATE---- REVIEWED BY ----------- ----- '`'`",- ^# I^ =------------------------------• DATE---- BUILDING PERMIT ISSUED------------------ �----_'r-------------------------------- DATE----------------------------- ---------------------------------------- ----- --- Alterations and/or recommendations:------_------------------------------------v ----------------------•---------- ------------------- ---------------- ---------------------------------I ----------------------------------------------•---- ---------------- -------------------------•--------- - t t r # I ---------`------------------------------------------------------- ---------------------------- °.t FINAL INSPECTION BY- -------------------- Date----- P ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Masellon Ave. 300 west Oak Street ,� 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California ✓ Manteca,California Tracy,California ES 9 REV15Ea 8-59 3M 3-'63 F.P.Cu. I