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FOR OFFICE USE: = { APPLICATION FOR SANITATION PERMIT Permit No. ........................ ----------- --------------- (Complete in Duplicate) _ / =----------------- ------ ---- - This permit Expires 1 Year From Date Issued Date Issued _______________________ 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 incompliance with County Ord' nce 549. JOBADDRESS AND LO TIO #-..- '------------------------------------------------------------------------------------- 10 p ----- Phone----------------------------------- Owner s Name ` - ---------------------------------------------------- Address------•---15TIOAddress------•---15 --••__ --- __ - Contractor's Name------------- --- -=---------- --------------------------- Phone--------._...._-----•-•----------- Install.ation --------Installation will serve: i Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _`,__ Number of bedrooms Number of baths _;�.-. Lot site _ ----------------•------------ -- Water Supply: Public system El Community system �ivate E] 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 ❑ New Constructions 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.) Septic 7a Distance from nearest well---- Distanc from foundation_/10-------- ------ __________________________ 5iz a/ Or G p.� Capacity f . Na. of compartments-----�._._ e Ye a...__ ._ Liquid de th--� ----- ------Ca acit ---- Disposak Feld: Distance from neares well___-.:" _._Distance from foundation--__ ®..__--.Distance to nearest lot line-47-__ Number of line -- - - Length of each line/ -_-`- --4�__.Width of trench._,--�_________________ Type of filter materia _Depth of. filter material__!- '________ Total length_-_�, _______________________ Seepag it: Distance to nearest well._.- -------- Distance from fou dation___C '_____.D stance to nearest lot line_______-- 6 ' Number of pits-_- ---.-------Lining material_ _-Size: Diameter__�-•�__�__._____-Depths��___________________ J Cesspool- Distance from nearest well__________-__-__Distance from foundation___________________ Lining material------------___________.___________ J r ❑ Size: Diameter-----" ------------------------------Depth--------------------- -----------------------------Liquid Capacity-----------------------------gals. 1 Privy: Distance from nearest well _____________________.-_------------------------_Distance from nearest building------------------------------------------ Distance ___________- __,_________--_____--- Distanceto nearest lot line----- --------------------------- - ----------- -------••------ -------------------------------------------------------------------- Remodeling and/or, repairing (describe):--------- --4_44�-------•------------------------------------------------------ ---------------------------------------------------- ------------------•-------------------------------------------------------•------------------;------------------------------------------ I ------------------------------------- -•---------------------------------------- ------------------------------•-----------------------•--------------------------------- _....-----------------:-------------- ------------ :-------------------------------------- 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, an rules and.regulations of the San Joaquin Local Health District. --- (Signed) - Contractor) ar) - -- ---------------- --.--_-------------- --- - --------- $r----------------------------------------------------=---------- --------- - - ----------------------- (rtle}. �� ------------ --------- (Plot plan, showing size of lot, location of sy in relation,to wells, buildings, etc., can be placed on reverse.side). 7, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYf ----------------------------•----------- DATE-----� -- REVIEWED BY TY- BUILDING ------------------------------------------------ DATE PERMITISSUED--------- --- --=-------------- tr-------------------" ------------------------------------- : DATE----------- ---`------------------- ,--------- Alterations and/or recommendations: '�� - � c -`' j ��' ------- ---- - - lL-1, I ----------•---- ----------------------------------------------------------------------------------------------------------------------------------- ! FINAL INSPECTION BY:..._a......' ? Date---' � -----------------------------S- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9•REVISED B-59 3M 3-'63 F,RC91-