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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------- ---11--------11--------- SANITATI ---------- ---------------------- ------------ .(Complete in Duplicate) dI ------------------------------------------------------- -- This Permit Expires 1 Year From Date Issued 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 wifh,Counfy P;dinance-No. 549, DRESS AW LOCATIO? I y JOB AD -c—J 1,�, t.K_-----it_ ____ I__1 o% X i ---- Owner's Name--- ----------------- --------------------- --- Phone-_- ------------------------- Address....&a.X I _7--- Contractor's Name_____ - -- --------- ------ •----------------------------------- Phone----------------------------- Installation will serve: Residence D Apartment HtOs! 0 Commercial F -1 Trailer C4urt-R( Motel E] Other f-I Number of living-units: N6m'ber ofU_e'5rooms Number of baths --- Lot size -------4r:----- Wafer Supply. Public'sys4e.m,E) Community system Private el'* Depth to Water Table ft. Char6cfer of soil to a':depth of 3 feet: Son I d E] Gravel [] Sandy Loam E] Clay Loam a y E] Adobe I-] Hardpan E] %, 1� Previous Application Made: '(If yes,date__..------7--------) No E] r New Construction: Yes [I No Ej FHA/VA: Yes E] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic-tank'or cesipoo-I permitted if public sewer is available within 200 feet.) Septic/ank: Distance fance from nearest ....Distances fro fn foundation----J-D-----------Material--- No. of comparfments_____�------------Size__,�1__�4_-S-_-------Liquid clepth-----151--t- ------------C a pa ci ty-4--4 Disposal Field: Disfance,from nearest welL-P . -------:.Disfance from foundation----1_4�.........Distance to nearest 16.t line---5 Nu'mber of lines___________/------- -----------Length of7each line------- -----------Width of trench___._____.___-) .Type of filter.mate - --------Yepfh of-filfier-material------!A-t---------Total length-----1_0Q------------------- --------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest ]of line__.__._____'----__ ❑ ine----------------- F1 Number of pits----------------------Lining material-----------------------Size: Diameter-------------- ---------Depf' -------------- ------- ---------- Cesspool- Distance from nearest'well-----------------Distance from foundation-------------------Lining material---------------------- E1 Size: Diameter------------------------------------- Depth- --------------------------------- --------------- -----------------Liquid Capacity--------------------- -----gI, Privy: Distance from nearest well_-------------I -----------------Distance from nearest b0d;ng--------------------------- % / ❑ ---------------- ------------- Distance to nearest ]of line____________________________-_____________-_-------------------------- :,� 11. / -------------------------------------- ------------------------------ Remodeling and/or :repairing (describe):__--___________________ --_--_--------_---- -_ --------------- -------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------- -------------------------I----------------------------------------------- ----------------------------------------------------------------------------------------------------------- -- --------- --------------- ------------------------------ -------------------------------------------- --------------------------------------------------------------------------------------------------- ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I laws, and rules and regulations of the San Joa uin Local Health District. 2 x (Signed]----------- ------ ze-_ -----------------------------------------------------*f0witirr—and/or Contractor] . 7 � -�&�'�a- _�-_--__.-- - c By:*----------- ------ ------- __*__ ' - 4�— �! --------------------------------- ---(Title)--- - --- ---- ---- ---- ---- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed..on_-reverse- - side).. FOR DEPARTMENT USE ONLY ----------------------------------- APPLICATION ACCEPTED BY------. `. _!!1-1.2 1 --------- ------- -_ -_ -- ------- - ---------------------------------------- ---- -------------------------- REVIEWED BY-------BUILDING PERMIT IS --SUED_- -_- - - DATE-- ---------------------------------------------------------------------- ----------------- DATE------------------------------------------------------------ -------------------------------------------•---------------------------------------- DA-TE_. Alterations and/or recommendations:------ --------------------- ------------------------- ------------------ - -------------- --------------------------------- --- ----- ------------ ------------------------------------------------------------------------------------------------------- i --------------------------- --------------------------------------I--------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ --------------------------- ----------------------_------------ ------------------------------------------------------------------------------------------------------------------------ -------------------------- --------------------- ---------- ........-------------------------------------- -------------------------------------------------------------- ---------- --------------------r.............--------------------------- FINAL INSPECTION ---------------------- Date----- - -r- -`G✓ SAN ate--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 13-59 3M 3-*63 F.p,Co.