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OR OFFICE USE; ---------- ---------- �----- ----------------------- ----_ APPLICATION FOR SANITATION PERMIT Permit No. -------------- - -------------------- - _ --- (Complete in Duplicate) 8' Y Date'Issued -3_'�.._.� m" This'Permit Expires 1 Year From 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 in compliance with County Ordin AZInce No. 549. JOB ADDRESS AND LOCATIO _. ` � - '�' M Owner's Name------=-- ---------------- - ---- ---------------------- ---------- - - - -�----- - - - ----- ---------------- -- ... Phone--------------------------------•--• Address ± ---------------- --- "--- -!� = -----------_---------- Contractor's Name-------•---`=„�; ---- -----�'� ---------------•--- Phone..__..----------•-••-•---------•--- p Installation will serve: ResidenceApartment House ❑ , Commercial ❑ Trailer Court C] Motel ❑ Other ❑ I Number of living tunits: --- ---- Number of bedrooms _ -_ Number of baths ---�__ Lot size .", - -: -----"------------------- J Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cay Loam ❑ Clay ❑ Adobe &'11ardpan ❑ Previous Application Made: Ilf..yes,date.................. ) No Ze-14ew Construction: Yes ❑ No �FHA/VA: Yes ❑ Nom TYPE OF INSTALLATION AND,SPECIFICATIONS: (No septic tank or cesspoo!'permitted if`public sewer is available within.200 feet.) Septic Tank: Distance from vnearest.well--------- --------Distance from foundation--------------------Material,____._._____._____.___._____---___-____.___-_. _"i 5f 4f No.sof compartments-#------------=-------`-Size--------------------------------Liquid depth--------------------------Capacity----------------------- :v Disposal Fi 14 `Distance from nearest well.................Distance from foundation_______._-___-__-__.Distance to nearest lot line----------------- AV15Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------------- Type of filter material._____________..---_.___Depth of filter material------------------------Total length-------------------__-___-______-_.__-_ Seepage Pit: Distance to nearest well-----------_-- Distance frp fo ndation____�r�_______.D stale to nearest lot line-_� - ®fir Number of pits........ _.._._.__Lining material___ Size: Diameter._- _.'..._.____Depth`. .... .... Cesspool: Distance from nearest well----- ---------Distance from foundation-----------------._ Lining material------------------------ SizeDiameter-------- -------- -------------Depth--------------------------------------------------._Liquid Capacity-.--------------------------gals. • r e ------.... from nearest building Privy: Distance--from nearest well------------------------------------ - 9------ ----- - ------ ----------- ❑ Distjance to nearest lot line------ -- ---- --- - ------ -----------------•--------------------------------------------------------------------------- Remodeling and/or repairing (describe):--------------------- ---: -- ------------------- - •---------------••---------------- I ---•-------------------------`--------------------------------------------------------------------------------- ----------- ---------- ----4--------------------------=----------------------------------------- i — - ---------------------------- ----------------------••------------------------------------------------------------------------ --------------------------- ---------------------------------------------------------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun+y ordinances, Stateilaws, and rules and regulations of the San .Joaquin Local Health District. (Signed)------------------------------------ --------f -------- ---- ------ ---------------------- # {®vr /or Contractor) I (Plat plan, showing size of lot, location of system in rela, to wells, buildings, a+c., can be placed on reverse side). a i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____.___ --- DATE._____ ______'z -. - -- ----~ REVIEWEDBY---------------------=---------- - ---- ----- ----------------------------------- --------- ------------------------------- DATE----------------------- iBUILDING PERMIT ISSUED-------------------------------------------------------------•--------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:----------_----------------- ._ __ - -- ----- -------------------- ----- -------- --------------------------------------------- -------- •-- ------------------------------------- ----- ----------------------------------------------------------------- - ---- -------- ------ - --------------------------------------------------------------- ---------------------------------------------------------- ------- -------------------------------------------- FINAL INSPECTION BY:.------- -`- �-- -- ------------------- -------------------- Date” ' ------------------------------------- �-----�0._.----�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hareltan Ave. 300 West Oak Street 124 Sycamore Sireet P.; r 205 West 9th Street Stockton,California Lodi,California Manteca,California y Tracy,California Jr.P.C o.