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rUK Ul-HCE USE: ---------------------------------------------------------- --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. Al!? ------------------ ----------------- ---------------------- ------ (Complete in Duplicate) ------------------------------- ---------- ------------- - This; Permit Expires I Year ear From Date Issue-d 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!X ,- -2 --------^L-------- -------- ., ------------ ----------- --------------------- ...... Owner's Name_____ IF—e—Y'n - - ---------------------- ---------------------------------------- Phone ------------T; Address--------------- ----------------- Contractor's Name_________________ ---------------- ------ -- --------- 16L------ -- - ------ Phone......_-------- _1 Commercial r_1 Hou rEl Commercial El Trailer Court E] Motel El Other Installation will serve: Residence Apartment ❑ Number of living units: Number of bedrooms Numberbaths/`_____ Lot size --- - Wafer Supply. Public system E] Community system El Private --------- Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E:1. Gravel ClaLoam Sandy Loam E:] y -E] Clay [I Adobe[I Hardpan Previous Application Made: (if yes,dcrte--------------- No 'Ej New Construction: YesEj No El PHA/VA: Yes El No Ej TYPE OF INSTALLATION-AND-SPECIFICATIONS:. (No Septic tank or cesspool permitted if public sewer is-available within 200 feet.) Septic Tank: Distance from nearest well___.___________-Distai4ce frdm--Joundation------------------- Material_.___--'-_- El No:. of compartments____--------------------size------- ---------- ield: Di: ----------- -L id depth----------Dispos geld: stance from nearest well__��_ ------Distance from fou'njati6n__ /------Distance to nearest lot line____F- Number of4ines__t-�.t A Length of each,line" Type of filter material,----- Depth,ofAR& material ------------Width of french...X----------- ------------ -----Total length---------4�0.40 ---------------------------- Seepa�ei t Distance to nearest well__/Oe- Distance frpn�joundafion 2f ----Z0_/..__.Disfance to nearest lot fine----------------- Number ,O' . of pits---- --------- -a el .40 Lining materi'_ ---------- �S j,,. Diameter ----Depth ------------ Cesspool: ------ Disfance-from. nearest weil--------------�SDist6nce from f6undafion---------------------Lining material-___--____.__.------- El Size: Diameter - I- . . ------------------------- ----- ------------Depth-- ----- ------------------ ----- -----gals. ----------------------Liquid Capacity-,--------------------- Privy: Distance from nearesf`wel____..-. 0 ,7 �.. .,L - .---_`-------------------------Distance from -nearesf,building,----------------------------------------- El';' Distance to nearest lot line_____-________._- 71 iJr--------------------------------------------- Remodeling and/or repairing, (describe):------- -------------- ------------------------------------------------------------- - ----------- -----------------------------------------------------------------------------------I------------------------------------ --------------------- ------------- ------------------------------------------------------------ --------------------------------------------- ---------------------- ------------------------------------------------------- --------------- --------------11---------------------------- ------I--------------------------------------------------------------------------------------- I hereby c6 rt ify th I have pre pak ------------------------------------------------------ #----------------------------------------------------- ---------- red this application and that the work will 6e done in accordance with San Joaquin County ordinances, State laws, a rules and!regulations of the San Joaquin Local Health District. (Signed)-------------- _- -------------------- ------ - ---- -- ----- ---- ------------------- 7- — - -- ------------------- ------��nd/or Contractor) -- ---------------------- --------- ---- -------------- (Plot plan. showing.s. Y By-------------------- ------ - '---1--_ Of lot, location system in la ton to w S buildings, etc.,can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__.__- ---------------------------------- REVIEWED ---------------------- --------------------------- DATE REVIEWED BY /& -------- -------- 2.......... ---- ----- --- ------------ -------------------------------------------------------L---------------- DATE BUILDING PERMIT ISSUED-------------------------------- - -----------------------------_------- ------- DATE Alterations and/or recommendations_________________._:__---__---._ __-------L--------------------I-------- ---------------------------------- ----------I--------------------------- ----------------------------------- ------------------------------*--------------------- -il ------------------- ------------------------------- --------- ----------------I------------------ ------------------------------------------------------ ------------------------ ------------------------ I--------------------------------------------------------------------------I--------------------------------------------------------- ------------11---------- I--------------- ----------------I------------------------------------------------------------------------------------------------------------;-------------------------------- -----------------------------:---------------------------- ------------------------------------------------------------- ...... --------------------I-------- FINAL INSPECTION BY:_.__-- - ------------------- ------------ ----- - ---------------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Avg. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 13-69 3M 3`63 F.P,120.