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FO OFFICE USE: -------------------- --- --------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------ -w ---------------------------- (Complete in Duplicate) �+ ' - --- This Permit Ex ices 1 Year From Date Issued 5 ' Date Issued/___.a -_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------- ------ 1�( � �.r ------------------------------• ------------------------------- Owner's Name----------Tom'►------ r ' 'f?'.1.dI-,r`------------r-----•---------------- ----- - ------------ ---------------- Phone../!.0_ � Address-------------------------�-7s �. --- ----- 1�'"f_ s -£ -------------------------------------------------------------------------------------------- Contractor's Name----------------- = =--------------•-------- -------------------------•---•------ --------------------------------------1- Phone----------------------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: ___I___ Number of bedrooms,. Number of baths -------- Lot size _____-...---________________________________________-.___ V� Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. (V Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sa y Loam ❑ Clay Loam El Clay F1 � Adobe[ANardpan [-I �1 Previous Application Made: (If yes,date--------------------) No KNew Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) +` Septic-T k: Distance from nearest well-____.__..___.__Distance from foundation-------------------Material_..._____.-_____--__---_.__________.._________. No. of compartments-------------------------Size------------------•-------------Liquid depth-------------------------.Capacity----------------------- Disposal eld: Distance from nearest weil___."� _._Distance from foundation___.___ Distance to nearest lot li �._-- Number of lines- .-- ---_ t___ ___________ Length of each line__________-. - ____.Width of french----- __ _ ----------------- Li _____________ �. f. Type of filter material_�_�iDepth of filter material----/�-__________Total length------f�tZ_Q___ __ _________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--..----------------Distance to nearest lot ine_____------.---.- ❑ Number of pits----------------------Lining material--------___--------Size: Diameter----------.------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material___.______________--.,--_----_____ ❑ Size: Diameter------------------ -------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well—--------------------------------------------Distance from nearest building--------------------------------------- . ❑ Distance to nearest lot line------ -------------------------------------------------------------------------------------------------------------•----------------------- Remodeling and/or repairing (describe):-------------------------- ---------------------•--------------------------------------------•----------------------------------------------------------- ------------ ------------------------- •--------------- :------- ----------------------------------------•----•---------------------------------••-------------- ------------------------------------------------ ---•--=----------a---------------------- ---------------------•-------------------------------------------------------------------------------- ----------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S ate laws, a rul s and regulations of the San Joaquin Local Health District. (Signed} - --------------- ----------------- ----------------------------- ------------------------------------------------(Owner and/or Contractor) By:------ •---------------------------------------------------------------------------------------------------------------------------(Tltle)------------------------------------------....- ---- --------- (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 BYE--------- ..0 t ------------------------------------------------ -------------- DATE---------/ --"ra.k47?&--------------- REVIEWEDBY----------------------------------------- ---------------------------------------------------------------- ------------------ DATE------------------------=---------------------------------- BUILDINGPERMIT ISSUED-----------------------------------------------------------------------------------------------------• DATE--------------- ----------------- --------------------- Alterationsand/or recommendations----------------------------------- -- - - --- - -----------------------------------------------•-- ----------------------- ------------------------------------ ---- -------------------------------- ---------t ----------- -----------------------------------------------------------------------------------------------------------_------------------------------- ---------------- -----------'r' ------------------------------------------ ---------------------------------------------------------------------------------------------------------------- --------------------------------- ----------------------------------------- -------------------------------------------- ------------------------------------------------------------------------------------------- M FINAL INSPECTION BY:---------- v 1 �t------------------------------ -- Date----- = --------------- -------------------------- III, SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi, California Manteca,California Tracy,California 99 9 REVISED 8-59 3M 3-'63 F.PAO. * �