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FOR OFFICE USE: ---------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------ ------- --- - - ---- (Complete in Duplicate) r Date Issued ---------- ------_ -- --- ------------- ------------- ---- --- ---- ---- This Permit Expires IYear From Date Issued Application is hereby made to the San Joaquin Local.Healfh District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ttf,� i -7x OD5- 3d'0-2,9- LYAO JOB ADDRESS AN -OCATIONJ, ---------- Owner's Name ....../04-4 --------------------------------------------------------- ------------- Phone------------------------------------- ------------------------------ ------Address.. .............4---------------- - -- --------------- ------- Contractor's Name----------------------••--- ---- ------------------------------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve- Residence House [] Commercial I-] Trailer Court ❑ Motel 0 Other [:1 Number of living units::____, Number of bedrooms OZ-- Number of baths -/---- Lot.size ___ ____'--------------- -------------------------------- Water Supply: Public'system',E] Community system El Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ❑Clay Loam 0 CIdy [] Adobe E] Hardpan Previous Application Made: {If yes,date-------------------- No ❑ New Construction: Yes 0 No Ef-' FHA/VA.. Yes E] No E] TYPE OF INSTALLATION AND SPECIFICATIONS: ': I i 1 1. T I - (No septic tank:or cesspool permitted if public.sewer is available within 200 feet.} 4 Septic Tank: Distance from neares.f.,well------_-_---_-Distance from`foundation--------------------Matmerial------------------------------------------------- El No. of compartments-------------------------:Size--------e-'o--------------Liquid'dep.W�----�----------------Capacity----------------------- ' e from nearest wll------------------Distance_2' Disposal Field: Distan-it-e q . from foundation----- --.__--.Distance to nearest lot line---_--------__--. ❑ ine----------------- El Number of lines-----------------------------------Lengtoof each line-------------------------------Width of trench-------------- ------ y,rF" T rench---------------------------T e of filter material-------------------------Dep+h of filter mater;�I-' --Total length-----:---`------.----_--------._-_---.---- - en fh------------------------------------------ yp ------------ 9 SeeXpae Pit: Distance to nearest well--------11-------Distance fr8m foundation-----/-,0---------Distance to nearest lot line----------------- - - s ----------- Number of pits--,/--------------Lining material-,,.,:� Depth--- - Cesspool: Distance from nearest well-----------------Distance from foundaf ion--------------P---Lining material-__-___-.._------.----- --- ------- 171 Size: Diameter--------------------------------------Depth----------x--------------------------------------------Liquid Capacity--------------------- -- gais.�., Privy: Distance from nearest well--------------------------------- --------- --- Distance from nearest building-_--_--_--.__._-___.----__.-_.___-___-. Distance to nearest lot line------------------- i 1� --------------------------------------------------------- 0 -- ------ -------F ----------------------------------------------- Remodeling and/or repairing (describe):_____... 0 ---- ---------- -7------------ ----------- ---------------------- -------------------------------- ----------- ------------------------------------------------ -- ------------------------- - -------------------------------------------------------------------------------------------------------- - -------- --------- ---------------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- --------------- -------------------- I hereby certify that I have prepared this application and that the work-will-be done in accordance with San Joaquin County IV ordinances, State law ds'L- and regulations of the San Joaquin Locdl'Healfh District. (Signed)------------------------- a--------------- -------- - ------- --------- ----------------------------------------- 7QER?7&nd/or Contractor) ----------------- -------------- -- By--------------------- ------ =------------- - ---------------jifle)-- ------------------ (Plot plan, showing size of,lot'locatiok of.system in relation to.we Is, 6uildi s, etc., can be placed on reverse_side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- ----------------------------------DATE-- Y.0-Y---------------------------- - - REVIEWEDBY------------------------- ------------------------------------------------------------------------------ --------------------- DATE------------------------------------------------------------- BUILDINGPERMIT ISSUED-----------------------------------:------------------------------------------------------------------ DATE---------------------1------------------------------------ Alterationsand/or recommendations:---------------------- - ----------- --------------------------------------------------------------------------------------------------------------------------- I -------------------------------------------------------------------------------------------------------------------;--------------------------------------------------------------------------------m------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------:--------------------I----------------------------------- -*-----------------------------------------------------------------------:--------------------------------------- ---------------------------------------- - - ------------------------------------------ -------------------------------------- ------------------------------------------- ---------------------------------I--------I------ .4 FINAL INSPECTION BY. ---------------------� - Date---- . ........--------------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California rs 9 REViBED B-59 3M 3-'63 F.P,CD.