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FOR OFFICE USE: -` S --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ... .._� --------------- ---------------- ----- -------------- (Complete in Duplicate) 'Z -------------- ��----------------- ---- ------- Date Issued ___ This Permit Expires 1 Year From Date Issued ___G Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. This a plication is made in compliant with County Ordinance No. 5 9 . OL57-- P g36s�, �( ,P JOB ADDRESS D LOCATION ---- --------- ------------------ 4 •. r G Phone-------•-----------------•------- Ownerl�s Namedg J2 Address--------- �2--------g-t-----1 ------- ---------- lA`- •--------------------------- -------------------------------•--- 11 Contractor's Name------------ ---•-- --------- ------ Phone----------------- -------••------- f Installation will serve: Residence Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: _f____ Number of bedrooms.> ___ Number f baths _- Lot size __ f �~---------------------- I Water: Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam E] Clay ❑ Adobe [3 Hardpan ❑ PreviouIs Application Made: (If yes,date-----------------A..} No F1New Construction: Yes ❑ No E] FHA/VA: Yes ❑ No Elk TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well__._�Q__.._Distan�cgfrom qfoun`d`ion__.__1_C1-.______-Mate ial__________________-_ __---_ ____.._._.___----.. No. of compartments-------- -----_----Size-(s--X/--1 --±k+-----Liquid depth-----5---------------Ca pacify-- Dispos Field: Distance from nearest well___, �__.._Distance from foundation_ f�_______._-Distance to nearest lot line S_ Number of lines_______ Length of each line--__-_ -3---- ........Width of trench.._, _._____.______________ Type of filter material__ -(2-,.-.-Depth_ of filter material___._ _ Total length------=4_4qil?--- ------- Seepilge Pit: Distance to nearest well______________________Distance from foundation--------------------Distance to nearest lot line---------------_. _4r ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- tm , 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----------------------------------------- 4 ❑ Distance to nearest lot line--------------------------------- ------------------------------------------------------------ --------------------------------------------- " Remodelingand/or repairing Idescribe):------------- ------- ---------- -----------•-- ------------------------------------- ------------- ---------------------------------------------------- �. I� ------••---------------------------------------- ---••--------•------------------------------------------------------------------------------------------------------------------------------------------ --. ---- -------------------------------------------------------•-------•------------------------__------------•-------------------------------------------------------------------- ---------------------------------- -- --- ------------------------------- --------------------- ------- ------------------------------------ ------------------------------------------------------------•---------------------------- IF hereby certify t I have prepared this application and that the work will be done in accordance with San Joaquin Count I ordinances, State Iifs, rules and re of the San Joaquin Local Health District. (Signed)--------- 1 --- -- --------- ---- - ---------- ----------------------------------------------------------- By:--- ---------------------------------------------------- d/or Contractor) 3 By:-- r ----- --------------- -------------------------__-----(Title)---------- --- ---------------------- _ ------ (Plot lan, sh size of lot, location of syste in relatioff wells, buildings, etc., can be placed on reverse side). I� FOR DEPARTMENT USE ONLY APP JICATION ACCEPTED BY---� - --------- - ---------------------------------------- DATE--J. -=-2--------- -X;F --------- ----- -- REVIEWEDBY--------------------------------------------- ---- ----------------------------- --_---------------------------------------- DATE-------------- -----•--------------------------------------- BUILDINGPERMIT ISSUED----------------------------------- ----------------------------------------------------------------- DATE------------------------------------------ ------------------ Alteritions and/or recommendations-----------------------------------------------------•----------------------------------------•- ------------_---- ---------••-•---------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•--------------------------------------------------- 1 �y------------------------------------------------------------ -------------------------------------------------------------------------- ------------- -------------•-------------- --------------------------------------------------------------------------------------------------------- ------------- -------•------------------------------------------------------ q FINAL INSPECTION BY:.,-A- .----- ,.r !/l/,1 ----------- Date-----f--- b Y ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street fl Stockton,California Lodi,California Manteca,California Tracy,California f es �9 REvis Eo 9.59 3M 3•'63 F.P.CM