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FOR OFFICE USE: . _ ---------- -- -------------------- `! APPLICATION FOR SANITATION PERMIT Permit No. ---------- 1 (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 LOCATION 1 -' -----.-••-------- Owners Name - ----- �Rh�------------------- ------------ ------ Phone----------------------------- _ Address-------- _ f------- --- ---------X7--53--�Z-------- ----•----- ------------ ---------•-------------------.._---------------------_--------- .---------------.------ ; Contractor's Name------•--------------- -------- --•-----------•-------------------• --------------- Phone----------------------------------- Installation ------------ - Installation will serve: Residence X Apartme Hausa ❑ Commercial ❑ Trailer Court ❑ /Motel [-] Other E]Number of living units: A---- Number of bedrooms'--,7-_ Number of baths ._�----- Lot size _____(f_�Q__-a � �.L�--•-•------------ I Water-.Supply: Public system ❑ Community system [-I Privatek Depth to Water Table . ft. �J ; Character of soil to a depth of 3 feet: Sand E] Grave! ❑ Sandy Loam F] Clay Loam ❑ Clay ❑ Adobe [ Hardpan I—] Previous Application Made: (If yes,date--------------------) No j New Construction: Yes`ZNo ❑ FHA/VA.. Yes ❑ Noj?�. TYPE OF INSTALLATION AND SPECIFICATIONS: f(No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ Septic Tank: Distance from nearest well___ '"Dis}once fr`oin foundatior'i�^ Ma)era /� --- = No. of compartments----2-eryry------------Size_3_�-f_CQ_-_k_--�-Liquid depth------ -------------------Capacityae -----_--- ; p Field Distance from nearest well_._r_Q:____.Distance from foundation_._. Q......- . ''stance to nearest lot lifer... ___ Disposal[ Number of lines__-..___. __ Length of each line__? - _''Width of trench ___ -`l" ________________ p i Type of filter material�.��e th of filter material_I_�_____ --.Tota! length___________1_�.�►________________ I Seepage Pit: Distance to nearest well-----------------------Distance from foundation____---------------:Distance to nearest lot line----------------- ❑ Number of pits--------.'--------------Lining material-----------------------size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation._..______-__----_lining material-----. --------------------------_ . ❑ Size: Diameter--------------------------------------Depth---------------;;►-�: ------- ----Liquid Capacity. .---------------------------ga . from ._ -- - �+ Distance from nearest wel--------------.-----------------------------------Distance nearest building-_---------------------------------------- Privy: ❑ Distance to nearest lot'line------------------------------------------- � ��/moi, Remodeling and/or repairing (describe):__ --- --- �- '� - ------ ------------------ k _______--.-,.______-__ t -----------------------------_-------------------------------------------------_______________________________________ 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 o the San Joaquin Local Health District. _ __Owner and/or Contractor (Signed)-- -- ------- By:__... ....-- ------------------------ ------------------------------•-------(Title)----- ----------------------------- ------- -------------- (Plot plan;s}iowing siie oof-Idt;'foc`ati6n=oof'system ii Trelation'to WBIIs,'buildings, etc„can be placed on-reverse_side).FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----------------------- --------------- ----------- ------------------------------------ DATE------------------------------------------------------------ REVIEWEDBY---------------------------------------------------------------------------------- -------------------- DATE----- _ .. .b----�..-------------.--------- BUILDINGPERMIT ISSUED-------------------------------------------- DATE-------------------�-------------- --------------- AI#erations and/or recommendations: -• --------- ----------------------------------------•--------•-----••---•---------------------•--•------------------------------ f ----------------------- -----------•-_------.....------------------------------------------------------------------------------------- ------------------------------------------------------------------- ------------------ ------ -----I------------ ----------------•----------------------- --------------------------------_------------------------------------ FINAL INSPECTION' BY------------ ---- - -------- Date-- ------------ ------ .......... -` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American street 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California E9.9 REVISrD 5-59 r.P.CO.ZM 6-60