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FOOFFICE USE:e f --------------------------------; -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ...!_b. � ------ -- -- ---------------------------------------------- (Complete in Duplicate) �� - -------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ______/__s. Application is hereby made to the San Joaquin Local HealthDistriet for a permit to c nstruct nd install the work herein descried. This application is made inc with County Ordinance No. S49. 1�10.Q�,�, IF JC3S ADDRESS AND LOCATION , 43 TOC IC l®N �7-3 -0I -k_ -- -------------------- Owner's Name------ ___ Phone___ _ _ Address----------------------------- 0' . "1__..' Contractor's Name------ �...__.. '----------------------------------------- ----- Phone.A06_9-- Q7------ -------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ --- Number of bedrooms _Z.--_ Number of baths ---I---- Lot size ------ ____r dR.•ar-------------_--.._---_ Water Supply: Public system ❑ Community system ❑ Private'jr Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date---------- .--_) No X New Construction: Yes ❑ No Dr FHA/VA: Yes ❑ No)o TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest ---Distance from�foundafion___�Q..._.........Matiriyl---t.(�ftl.. ___ _______________ VA ` No. of compartments-----.__�-.-_-__-..-Size_�_-_X___�_._._X.$-_-Liquid depth--.�-_L. -------__-.CapacityR�_ Disposal Field: Distance from nearest well_________________Distance from foundation-----------____._-.Distance to nearest lot line----------------- 171 Number of lines-----------------------------------Length of each line------------------------------Width of french---.--------------_--------_--_---- �r Type of filter material_________________________Depth of filter material-----------------------Total length----_-_--___----:---_---_______________- [[..•rr Seepage Pit: Distance to nearest well----- ---------- -----Distance from foundation--------------------Distance to nearest lot line----_--.----_-_-- ❑ Number of pits----------------------Lining material----------------------.Size:.Diameter_--- ------Depth--------------------------------- J' Cesspool: Distance from nearest well---------------_Distance from foundation--------------------Lining material--.-.-.-_-----_---------__--_-_---_._ 1 ❑ Size: Diameter--------------------------------------Depth-------------- ------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------_-------------r-----Distance from nearest building-----------------------------------__ ❑ Distance to nearest lot line. --------- r---------------------------------------------------------------------------------- Remodelin and/or re airin (describe): +.�s .a.e.��_ 9 / p 9 K «--- ".= s -- ds. -------- i 4' ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-----------loo. �__________________ -------. Owner and/or Contractor) By-------------------lQck-.,,---- r - ------------ -----------------------------------------(Title)------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED $Y--- .51,------------ -------------------------------------------- DATE---------' = G = REVIEWEDBY------------------------ ------•-------------------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED.----------------------------------------------------- --------------------------------- ------------- DATE-----.- --------------------------------------------------- Alterations and/or recommendations------------------------------------- --- _:--------------•---------------------------------------------------------------------------------------------------- ----------------------- ---------------------------------------------------------•------------------------- -------------------------------------------------------------•---------------------------------------------------------------------- --------------------------------------- - --- --------�---- - -- - --------------------------------•-------------- ------- ----- --------------------------------- --------------------------- ;��_ -------—--------------------- , FINAL INSPECTION BY:. Date -/-------�----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REWSED 5-59 3M 3-'63 F.p.CD. t'