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FOR OFFICE USE: - - ---------- ""`-- ------ --------------- ------------------------ APPLICATION FOR SANITATION PERMIT Permit No. .?.: ..------------- (Complete --_.-_-_ n - (Complete in->Duplicate) -- ---- --- Date Issued ...... ___________________ _ __ _____._____.________._.___ 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 Ordinance No. 549. JOB ADDRESS AND LOCATN--•... .. 1 — - -------------- Owner's Name------.2/- - - -- - -- --------- Phone-------------------••---•---- Address.----- y :.. _ - .-_ - Contractor's Name --- " = Phone. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-_. N mber of bedrooms _ .. Number of baths _l___ Lot size om---------------------------- Water SuPPIY� Publics stem. Community system El ❑ Depth to Water Table !Wit. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe. ardpan ❑ Previous Application Made: (If yes,dates ________________) No ®'-New Construction: Yes ❑ No Fj— HA/VA: Yes ❑ No [!1— TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.). $qptic Tank: Distance from nearest well------------------Distance from foundation-------------------Material......................................_._____.._.. No. of compartments---------------------------Size__________ ____________________Liquid de th____.______-____.____..___Capacity-.- Disposal Field: Distance from nearest well____ ----Distance from foundation-__.l,P__ ____.Distance to nearest lot line.....8 .... . r / Number of lines________ _______ _ I Length of each line____-_��I______________-Width of trench._��_____.__;__..._.__-___-__-__ -------- Type of filter material __ r -6 / ' YP ��t ._Depth of filter material- �l�_-___--_---Total length------'�'Q---------------------------- Seepmage�t: Distance to nearest well________—'._______Distance fr m foymdation__—__:____.Distance to nearest lot line__ _______ L� Number of pits-----l___________ _Lining material,._/GPG--_-__-ti"Size: -.-.____--_._... Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material______.__-____.________.____________-. ❑ Size: Diameter--------------------------------------Depth--------------------------------------------- -----Liquid Capacity----------------------------gals. Privy: e Distance from nearest well---------------__________________________________Distance from nearest building.______._____.________________.__________- ❑ r-.. , - — . Distance to nearest ilot'line---------------i------------ - -----------•----- ..........•------------------------.--------------------- Remodeling and/or repairing (describe)________________ F •--------------•-----------------------•-------:------•----------------• ------------------------------------------------ ---- -------------- •----...._------•-----------------------•---•-------------------------------------------------------••-------------------------------------------------- .y ---------------------------------•--•--------------------------•-----•---------------------•------------------•---------------------------------------------•----------------------•- ---- --------- 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, and rules and regulations f the'San Joaquin Local Health District. :. (Signed)-------- ----- -------------------------------------------------------- ---=-(0iiiii9Erd%or Contractor) i ' --=------- - -- - --------------------------------------- Title ,C ------------------ ------------------ (Plot pian, showing size of lot, location of s em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----C.-- .;_�� --------------------------------------------------------------- DATE---z - - ...................--------------- REVIEWED BY -------- ---------------- - •---------- -------------------..... DATE--------------------=-------- -- -- ----------------------------- BUILDING PERMIT ISSUED--------------------=--------------------------------------------------------------------------------- DATE.-- -------------------------------•------------------------- Alterations and/or recommendations ,___:: --_. I - - " y -------------------------------------------------------------------------- ---------------------=----- FINAL INSPECTION •BY:---r - -- -- ------_.-:_�---------- Date--------~-`--- ----- k--------------------------------------------------- SAN JOAQUIN LOCAL-HEALTH DISTRICT 130 South American Street 200'Weef Oak Street �'y j j 144 SyiFd ore Street 405 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California' S' E5•9 REVIBED B•59 r^=,2M 6-61: