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FOR OFFIU U •E: ---------------_ --..------------_ APPLICATION FOR SANITATION PERMIT Permit No. ...�• _�._1 ------ -------• --------- - ---------- ------- --------- (Complete in Duplicate) J- 1 . Date Issued _._...____________________________________________________ This Permit Expires 1 Year From Date Issued -------�.-�---L- ' 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 Ordina ce . 49. JOB ADDRESS AND LOCATIO --------- ----------------------------------------- Owner's Name------------ ----------- -------------=°------------------ ------------ Phone..__....---------------------------- Address-------------/ ---. . --------------------------------------•- Contractor's Name------------------- �� - /��-------- ------------------------------------- ...........:--------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedroomsNumber of baths ,_ _________________________________ Water Supply: Public system 9T1_C_0mm,nity system-❑E.„Private E] .Depth to Water Table _,/ t. 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 Construction: Yes -No F] FHA/VA: Yes Z3 E] TYPE OF INSTALLATION AND SPECIFICATIONS: 5, (No septic tank or cesspool permitted if publicsewer is available within 200 feet.) No. of com artments____ Sier, (� dation___ ��______.Mat �l._____ _G __- __ ___-_ __ ` `.� ------------ Septic Tank: Distance mpm nearest w ___�'__Distanc r fours* Liquid depth__ __.________Capacity___ ��'/_____ L� / l p tion----________--------Distance to nearest I t line---_____--------- Number ofolines eare�t well-; _:---- --- Length of each linea ____ ___________Width of trench___ Type of filter material124EV-1®Q epth of filter material___ ( �`_______Total length_____ ___------------------------- f, ---_----_______________ W Seepage P' Distance to neares�tt}well-.____-___Distance from fou da tion_.__.1�.!_,.Distdnce to nearest lot line_t��!___. Number of pits----9.I____________Lining material___ Q � ____ ��$ize:'Diameter__. .___ _.Depth-__,cZ�__.,1� 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.__._...__________________-__________.._. ...�.r .._ .. . ., .. , ❑ Distance to nearest lot line. ------'- -----,---/---------------------------------- ; Remodeling and/or repairing (describe):--------'`/T�'�� ----------- ---------------------------- ------------------------------------------ _ ;k -'iv __ _ __ _ _ ___ _ _ _ _ _ _ _ _ _ _______.____..____________-____.____.______-__.._____________._________________.__._._____________-_______________-_._____-___- ------------- I __------ ;I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County'., i ordinances, State laws, and rule and regulations of the San Joaquin Local Health District. (Signed) ------ ---------------- -- -- --- ----- ----------------------- ------------------------ Contractor ---------Title - - ----------------------- - -- - ------------------- (Plat plan, showing size of lot, location of s ` in relation to wells, buildings, etc., can be placed`on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - RATE-• 771--�1----------------- ----------------- REVIEWEDBY---------------------------------------------------- --------------------------- -- ----- ------------------ --•- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DAT E..--------••------------------------------------------------ Alterations and/or recommendations:---- ---"-- ----- -------------------•----...---•----------------------------------•-------•----------•---•----------------. ---------------------- ---------- f --------- -------•----------------- -------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ -----------I----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- ----------•--------- -------- ------------------------------------------ FINAL INSPECTION BY ------• ------- ------------ --- ------ Date-------------31.-F--lU--------------------------------•---•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street; , i 2q Sycamore Street 205 West 9th Street J Stockton,California Lodi,California Manteca;California Tracy,California ES-9 REVISED 5.39 r.p.DD.YM 6.60