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FOR OFFICE USE:, -------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No....1..a.�.. --------------------------------------------------------- ... f --------------------------------------------------------- (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. 55449. JOB ADDRESS AND L CA --- 1. TAT t�h� ! < -----•--------------------------•---..'b -- ----- Owner's Name. ► - ) Phone . Address .............. -- " 1- --- -- -- •-- - ---- - --------------- -----------------------------•------------...-------------- .......---......... CoJ%aAQ ....-------•-------•-•-- ---• --------�---------------------• •-------- Phone .............. .................... InsPgAti % will serve: 10esidence WApartment House ❑ Commerciy ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/-.. Number of bedrooms -----t Number of baths ____L Lot size ..••-----__ _.._zr'n..X.JeW---------------- Water Supply: Public system E] Community system )d Private E] Depth to Water Table _f . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 0ir Adobe ❑ Hardpan ❑ Previous Application Made: (If yes, date____________________) No New Construction: Yes -4 No ❑ FHA/VA: Yes ❑ NOINr TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sew r i available within 200 feet.) Septi Tank: Distance from nearest well...., s nc frQj"�uAd ion...;._/Q_____-Materi I___-••!�------No. of compartments_____ _._____-__ �z ____-l�___ Liquid dept_.___..._ ._ .Capacity_-__ Dis al Field: Distance from nearest well__,___..__.. tante from foundation___ ....____!=.... Distance to nearest I Number of lines-_--_�_______ ____________ ___ ength of each line_______-_-. . ......... Width of trench._._ .._ �� - - : -•- ---------------- Type of filter materiai___Depth of filter material____ ________.____Total length____...4a_________________________ Seepage Pit: Distance to nearest well_____________ _______Distance from foundation .................... Distance to nearest lot line ----------------- 0 Number of pits ---------------------- Lining material ----------------------- Size: Diameter ....................... Depth ................................. 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 __-____-_-__-___-___-------_.__--_-_-_-._. ❑ Distance to nearest lot line -------------------------------------- ---------------------------------------------------------•----------------------......._.......------. Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------- ------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------ 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 of the San Joaquin Local Health District. (Signed)---/dt ...... i L-' ------------------------------------------------------ -----------------------------------------------------------------(Owner and/or Contractor) By:----;. --•-- -----------------------------------------------------------(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 APPLICATIONACCEPTED BY ------------------------- -------------------------------- --------------------------------- DATE--..................... ................................. REVIEWEDBY ---------------------------------------- .---- ------ ----- --------------------- :--*E ........................................................... PERMITISSUED .................................................... . --- •-----..... --A- DATE ............................................................. and/or recommendations:. -----------------------•-- •-------------------•-------------------------------------------------------------------------------------•••--•----•-------.---•---------•-------------------•----•-•--•---•--•--.------....--------------- --------------------------------- I ------------ - ----------------------- ---------- ........................................................................... ..................................................... -------------------------------- •..................................................................................................................................................................... ---------• ----------------------------------------------------------------- - ------ ------ - ---•-----------------------------------------------...........------------------------------- -----------•---- FINAL INSPECTION BY-------------------- --------------- .----Zi Date --------------------- f `....... w../................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton, California Lodi, California Manteca, California Tracy, California EN -9 REVIIED 8.39 ♦.P.CD. 2M 8•e0 1