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FOR &FICE USE; 4 ---------------------- ----- -------------------------- APPLICATION FOR SANITATION PERMIT Permit o. ........................ --------- -------------- ---------------------- ----- --- (Complete in Duplicate) /1!1 ..� -_,.------------------_ -------- .-..--.---..-_.----- This Permit Expires 1 Year From Date Issued Date Issued ----I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrbed. This appli8ation is made in compliance with�C'ouunty Ordinance No. S49. JOB ADDRESS ANI CATI�N-----_F_..-��1 - �'' --- al ---------------------- Owner's Name--- --s ------------------------ - Phone-----------•------------------------ �E _ --------------------------------------------------------------..----------- Address---------- .�------- �' ----- --- - --•--------•-----�----- Contracto' 's Name---------------- -- ----------------------------------------------------- • Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I Number of living units: --- _-_ Number of bedrooms - 'Number of baths _-�--_-_ Lot size -tt. �---. ------=�- ----------- ---- Water Supply: Public system ❑ Community system ❑ Private [ � Depth to Water Table —1 Characte� of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay Adobe [3 Hardpan ❑ Previous App{ication Made: (If yes,date--------------------) Nq�a New Construction: Yes No ❑ NA/VA: Yes ❑ No TYPE OF� INSTALLATION AND SPECIFICATIONS: _ ,_ u ... (No septic tank or cesspool permitted if public s7er is available within 204 feet.)/ ,F Se • Tank: Distance from nearest _ tfrom.Avuod-a _ -- = --at �4 --------- zeaNo. of compartments--- - --Si -_tA- Li uid de th--.__ wY'7,ZCa acitY ;�__ ------ Dis al Field: Distance from nearest well__j-A ....Distance from foundat'on----�c�---_--_Distance to nearest lot line-115,4------- 1° Number of lines--�-------- ---------------Length of each line--- C'--- ------ ------.--Width of trench.-----e-4 . ----------------• . Type of filter material--5-1. ___Depth of filter material-----/__ ...........Total length-------1642-----_----------------- •Seepage Pit: Distance to nearest well----------------------Distance from foundation--____.-.-_----__-.Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material-----------------------Size: Diameter------------------ ---Depth.------------------------------- ❑ Distance fronearest well-----------------Distance from foundation _ foundation- material------------------------------------- Cesspool from nearest Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity------------------ gals. Privy: j - ` Disfancefrom nearest weft- -'-.-_" --_- --'--- ----------.--Distance from nearest building----------------------------_-----------. ❑ 1 Distance to nearest lot line--------------------------------------------------------------------------------------------------------- ------------------------------------ 1 l Remodeling g and/or repairing (describe):-------------------------------- ------------------------------------------------------------- -------------•-----•----------- ------------------------ -----------------------------•---------------------------==----------------------------------------------------------------------------------------------------------- ----------------------------------------------------- -------- ------------------------------------------- --------------------------------------•---------------------------------------------------------=-----------------------------------------------------------------------------------------------•--- -- I �k � � --------------- -- I heileby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County i ordinan�cels, Staff {a s, and rules and regulations of the San Joaquin Local Health Distr�,.ict. {Signed).-i_._---- -_ _ � --- ----------(Owner and/or Contractor) --- --------- ------ ---------------------------------- -- By------------------------------------------------------------_----------------------------------------------------------- { itle) - (Plot plat showing size of lot, location of system in relation to wells, buildings; etc.,.can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- ---------------------------------- ---------------------------------------- DATE------ ----------•----------------------------------------- rREVIEWED BY---------------------------------------------------------------------------------------------- - - --------- DATE----- BUILDING PERMIT ISSUED------------------------------------- - DATE _ ---------- Alterations and/or recommendations:------- ------------------------------------ --•------------------------------------------------------------------------------------------------------------- ---------- ---- ----------------------------------------------------- -------------------------------------------------------------------------------------------=------------------------ ------- l - - ------------------------------------------------------ FINAL. ----- ---------FINAL INSPECTION BY.. ---------------- ----- Date F�---------T`------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ffa:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3--63 F.P.CD.