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I rUK OFFICE USE: ------------ -------------------------_ _______ z k- ------ -----'------ ----------- ----------- --------- -- APPLICATION FOR SANITATION PERMIT Permit No. z(Complete in Duplicate) . 4 �� __. .. D Issued 'bs- his Permit''Ex ires 1 Year from Date Issued �� ---------------------------------------. - ---------- --- � ate ssue Application is lleeeby made to the San Joaquin Local Health District for a permit to construct install �e work herein described. .This a plicationis made in cliance with Count Ordinance o. 5 9. 4"0- 0,3 :JOB ADDRES! D L CATION._--_!_'1.4_-__.- ll r. p-�.o Owner s'Name--------- ---__ - -- - one-=---_-----••-------•-•----•--------- _ Address_'• �Z---- , - } actor's Name - ------- ° -------------------------- -------------- Phone.------• ..'!- ontr Installation will serve. Residence Apartment House ❑ Commercial Trailer Court r ❑ ❑ Motel ❑ Otheri❑ Number of living units:,_/---'Number of bedrooms _ -- Number�f baths <Lof size _{ Wafer Supply: Public system.❑. Community system ❑ Private K Depth-t -WaferTable.sl__-._.'ft. Character of.soil to a depth of 3 feet: Sand Gravel W ❑ ❑ . Sandy:-Doam _ Clay Loam ❑ Cley'❑ Adobe Y ❑ F Hardpan ❑ x Previous Application Made: (If yes,date___________ ________I No ❑ Now Construe iot n:Yes''❑ No❑ FHA/VA: Yes ❑ No ❑ j TYPE' OF INSTALLATION AND SPECIFICATIONS: '' t J (No'septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------..__--Distance from foundafion------------------_.Material_____-_.._____._ ❑ No. of con partmencs------------ -------....--Size-----------------------•----- Liquid depth__.= '- Y ' Capacity i Dispos field: Distance from nearest well_.��--------Disfance-from'foundation---- tstance--`to nearest lot line_A. ---------- Number of lines----------- ---------------------Lengt-h o ea-c-i lirie_:_—_� --_L- --:- : Width_ of trench__` -- -----,-- ------------ Type of filter material____________ ___---___Depth of filter material---------`_�1_-,,,-.Total length-------1A! -------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to"nearest lot line------__---_-____ ❑ Number of:'pi#s----------------------Lining material---------------------- Size: Diameter----- ° =.Depth------------ T Cesspool: Distance from nearest well--------------___Distance from foundation__- :_-Lining mate pial_._..__.____._--- ----- Ej Size: Diameter--------------------------------------Depth--------------------------- -------------- --_----.Liquid Capacity----------------------------gals. Privy: � ;r : Distance from nearest well-------------------------------------------.-----Distance from nearest building - Dis#ante to nearest lot line_________________________.___.___._- . Remodeling and/or repairing (des ribe'____ __________.___-k-----_-.-_ x E ----- -----------------•- -- r � ------------------------------------------------ e -- ------ --------------•-------•------------ F. __________________________________________ i _________________________________:_.__._____.__.________-«__----___--- .-_--___-----____-_ - 1 hereby certify that'i have prepared this application and that the work will be done in accordance with San Joa t .ordinances, Sta s, and rules and regulations of fhe San Joaquin Local Health District. quin County Si nt3d --- --- ------ -- ------- ---- --------- ----------------------------------------------------------- � BY= - ------------- --•------ riation - - - an r Contractio ---- ------(Title)---------------------------- - --------o ----------- or. (Plot plan, showing size of lot, location system in r to wells, buildings, etc., can be placed on reverse side). i r FOR DEPARTMENT USE ONLY } APPLICATION ACCEPTED 8Y_ - DATE1 - . -------------- REVIEWED BY ---- : ------------------------------- -------- DATE BUILDING PERMIT ISSUED-------- --- ----`-------------------- --------- DA•TE--------------------- Alterations and/or recommendations:_ -------------- ----------- ---------------------------------------------------•-•-•-------•----------------•- -------------•------------ ------------------------------------- - — --------------------------------- -------------------------- -- ------------------- ---------------------------------------- --------------- =- FINAL INSPECTION BY:.-,'-. r' ?-r.� Date SAN JOAQUIN LOCAL HEALTH DISTRICT Ilk } 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 Wes!9th Street Stockton,California Lodi,California Manteca,California Tracy,California i - ES 9 REVISED 8-59 3M 3-'63 F.P.Qp, J}i� _ i