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FURUFFICE WSE: -- - ---- - _ ---- ----_._----- APPLICATION FOR SANITATION PERMIT Permit No. /•� -.. S ..- ... (Complete in Duplicate) ////zz '-----' ----- -- ----- This Permit Expires 7 Year From Date Issued D- aii"* ed f°Z)//._1..0 �! u // Application is hereby made to the San Joaquin Local Health District fora permit to construcYeni �L'�O—O f This application is made in compliance wi p elvor erem escrbed. p County Ordinance No. 549. JOB ADDRESS AND LOCATION..... -G¢ :.-_-/ ,---- Owner's Name__...._ Address` -- Contractor's Name-.------'--- - --------- . - Phone--------------------------------- Insfallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /----- Number of bedrooms _ ._ Number of baths _/__ Lot size ----- Water Supply: Public system ❑ Community system ❑ Private V Depth to Water Tableh.<ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: (If yes,dote ................I No E] New Construction: Yes ❑ No� FHA/VA: Yes E] No E]TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pti Tank: Distance from nearest well_._ -------_-Distance from foundation....._.____.------Material.__ p No. of compartments ... ---------------- Size... _. ..------_-----Liquid depth ___ _. ----- 1 l -- Dis�I Id: Distance from nearest well.S' f Distance from foundation0- Distance to nearest lot llne_3 ... ... Number of lines........ �' _.Length of each line_�LD.___. ..Q._...._.Width of trench._.._ _- Type of filter materials(�D_C�..Depth of filter material---A ."__.Total length--------------....LoD--'--_- Seepage Pit: Distance to nearest well ---------------------Distance from foundation......-------------.Distance to nearest lot line--------- ❑ Number of pits----. Lining material,--------------- Diameter. ._...._... _..Depth._....__.._.. Cesspool: Distance from nearest well-------.. ------Distance from foundation--- ---_.-------- Lining material_.__...._....----_--....___.. ❑ Size: Diameter-----------------------------Depth...-------------- ......Liquid Capacity------------------------gals. . Priv Distance from nearest well Privy: _---------------- ----------Distance from nearest building------ -----------------------_---_ �. ❑ Distance to nearest lot line.._---- -------------------- -------------------------------------_.___------- O Remodeling and/or repairing (describe):---- ----- ----- --------- ----------- ------------ ---" - -------------------------------------------"-------------`------------------_---------------------------------------------------------------------------_------ ------ ------- ...----------------'----------------------__-------------------------------------------------------------------`----....._---------------`----------------I-----------------'------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Slyqaws, and rules and regulations of the San Joaquin Local Health District. ned ',A., o r " (Sig ) c -��"�------ - - - --.._..---- --- ------ wrier and/or Contract ��... rid/o or) By:. -- - - -�1/ ---- --...(Ti+le) ... it - (Plot plan, showing size of lot, location of Sys em in relation to wells, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------- - - --- -------- ------------- ---------_ DATE-----.-------------- -- - - - REVIEWEDBY.---------------------------------------------------------- -----------...._...----------................... -------- DATE - -- BUILDING PERMIT ISSUED-------------_-------------- ' - --- --------___--------------- . DATE------------------------- --- - -------------------- Alteraf ions and/ recce'yndati s: ____----- - ------- - __-.-_-------_-__ - -'- - -------- - - vs..... f�------1�+� �.'�-- �! .Br 0 , ;I -------- ------------- -------- ---------------- - �4�- __40e,a, �' ---------------- - -------------- ------ ------ ------------------------------------------------------------------------------------------------------------------------------- - -- - - - -- --- - ... . --------------------- - ---- - FINAL INSPECTION BY:- - -. - Date - - ` ----------- SAN -- - _....._._. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazelton Ave. 300 West Oak Street 124 Sycamore Street 705 West 9th Street Stockton, California Lodi,California Manteca, California Tracy, California ES 9 NEVISED D-59 3M 3-'63