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OR OFFICE ---- --- APPLICATION FOR SANITATION PERMIT Permit No. ---------------- ----------- ------------------------- (Complete in Duplicate) Date Issued ---------------- ----------- This Permit Expires 1 Year From Date Issued Application is hereby-made to the San.Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. :30ez` JOB ADDRESS AND L CATION...... ... ----- -------------- -------------------------- ------------/--------------- 1 6;;; ..,_j,-R :5�1 r- - -------------------- �wne�'s Name.------- ----------- --------------- ------------ --------------------------------- Phone — -------------------------------------------------------------------------------------- Address------------___--------------____.................................../------ - ------------------- Contractor's Name_----_----------- -------------------------------------------------- ------------------------------------------ Phone........-------------------------- - Installation will serve: Residence Cj--�Aparfmenf House 171 Commercial E] Trailer Court El Motel 0 Other 13 Number of living units: Number of bedrooms ---! Number of baths _..el.. Lot size ------- --------------------------- ----------- Water Supply: Public system E3 Community systern E] Private [�Bepth To Water Table ft. Character of soil to a depth of 3 feet: Sand Ej Gravel El Sandy Loam 0- Clay Loam [] Clay 0 Adobe E] Hardpan 0 I - Previous Application Made: (If yes,date------ -___________I -No [ --New Construction: Yes ❑ No Q_FHA/VA- Yes C] No ET- 1 TYPE OF INSTALLATION AND SPECIFICATIONS: is available within 200 feet.) (No septic tank or cesspool permitted if pulalic Septic Tank: Distance from nearest Distance from foundation___ _ ---------Material.......... r -----------�11--------capacity_----- No. of compartments---------:�......�._Size---------- --Liquid depth-- --- om I � I e r-"'' J.-,F I Distance from foundation-__3-_5?t-------Distance to nearest lot I n Disposal Field: Distanc f nearest well.-... --------V idth of trench_________________---?k —.------ Number of lines------------ -----------Length of each line---------- Type of filter of filter maferial____ X__*-------Total length---------- ------ --- ----- % . -Depth Seepage Pit: Distance totnearest well_--_----}____-_-__I- Distance from foundation....................Distance to nearest lot line._..____---.____. i * ----------- ElNumber of pits----------------------Lining r6ferial-----------------------Size: Diameter----•----------------- Depth-----•--------------- -------------Lining material------------------------------- Cesspook Distance from nearest well------!t--------i.Distance from foundation Liquid Capacity----------------------------gals. ElSize: Diameter----=------------------- -------------Depth---------------------------------------------------- Privy: Distance from nearest well------------------\-----------------------------Distance from nearest building------------------------------------------ Distance to nearest lot line_______________ ....... I ----------------------------------- ---------------------------------------------------------------------- 0 ------------------- Remodeling and/or repairing (describe):------------------------------%-----------------------------------------I----------------------------------------------------------------------- -------------------------------------------------------------------------- ------I----------11--------------------------- -----------------_- ------------------------------------------------------------------- ------------------------------------------------ -------------------- -------------- ------------------------ ------------------------------------------------------------------------- ------------------!t. ------------- ---------------------------------------------------•---------------------------------------------------- ------- ------------------------------------------------------ -------------------- I hereby certify that I have prepared this application and4hat the work will be done in accordance with San Joaquin County ordinances, State la s, and rules and regulations of the San Jo'a'quin Local Health District. (:22 ---------(Owner and/or Contractor) (Signed)----_--------------- --------------------------------------------------------- ------- - ---------------------I------------------ --- ---- -------------- ---------------------------------------- -------(Title) By:------------------------ .-_;/) relation to wells, buildings: etc., can be placed on reverse side). [Plot plan, showing size of lot, location of system in R. DEPARTMENT USE ONLY -------------------- --------------------- DATE APPLICATION ACCEPTED BY---------------- ------ ---- - -- ------- -------------------- -------------------- DATE-----------•--------•------------------- ------------------- REVIEWEDBY-------------------------------------------------------------------------------------------------------- DATE. -------------- --------------- BUILDINGPERMIT ISSUED-----------------------------------------*----------- --------------**------------------------------* I -----I----------_------------------- Alterat ns an /or recommencta+ions----------------------------- ----- ------------ ---------------------- . --------------- Y. ------- ........ - ---------- ---------- _,ef—------f-.-A—.---�490---------------------dC ---- ---------------------------------------------------------------------- ----------------------------------------- .......... ------- ...?"------;------------ FINAL INSPECTION BY:.__-.._- '1v Date------- --- ---------------- --- t�--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak$'root 174 Sycamore Street 205 West 91h Street .Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVtSED 8-S9 2M 5-62 ATLAS