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ICE USE: ` �I �.� --------------------------- I r ----------------------------- ------------------------------I-------------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------------------------- ----------------------------- (Complete in Duplicate) Date Issued ----------------------- ------------------------ This Permit Expires I 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. 's application is made in compliance with County Ordinance No. 5 JOB ADDRESS AND LOCATION ----------------------- ............ I ................................................................................................... J Owner's Name............ -------:------- ..&--------------- --------------------------- Pho. Address ............................ .... 1- -------------------------------------------- ------_-------------7.7............ . .. . .. ........................................... Contractor's Name_.�, .......... . ......................................................................• Phone----.......----.............------. Installation will serve: Residence x, Apartment House 0 Commercial []1. Trailer Cour4 ❑ Motel [] Other 0 jNumber of living units: ... Number of bedrolms ...3**OoNumber of baths ...I-_- Lot si ...................... Water Supply: Public system EI-X- ommunity system I>( Private F1 Depth to Water Tawe2,4ft. Character of soil to a depth of 3 feet: Sand E] Gravel [] Sandy Loam 0 Clay Loam 0 ClayX Adobe[I Hardpan C3 N, Previous Application Made: (If yes,date---------------- Y� NoNew Constr I ucti6n: Yes NR�< FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPEtIFICATION& (No septic tank or cesspool permitted if public sewer iscavailable within 200 feet.) Se nearest ell__ A 1 Tank: Distance from n well_. Distance from foundation..../.w...... ...MZarr�l... -Z------ --------- ------- No. of compartments____ ----------__________Size..._.'Ty�110-I&I-1 Liquid a .-Capacity--- p:t ------------ Disposal Field: Distance from nears well---4?&LODistance from foundation... ..........D' ..M�Ith ance to nearest lot-line,50-00 of trench.._ .....f ...... Number of lines-------t-------_--------------Length of each linev72- -. .3-121 _t i Type of filter mate ria 151FV*C41�t---Depiv of.-filter mate rial./!&-*-- otal length...ch__311-_-�r, --------------------- Seepage Pit: Distance to nearest well----------------------Distance from,foUndation............I.....Distance to nearest lot line.........._...... ❑ Number of pits----------------------Lining material-----------------------Sije: Diameter,i.....................Depth..._._..___..___....._..____..... Cesspool: Distance from nearest well._________._ _._Distance from foundation....,. Lining material.....................................❑ . Size: Diameter------------------------------------.-Depth............................. ------------------L..Liquid Capacity------------_-------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__________________________________________ ❑ Distance uilding------------------------------------------ Distance to nearest lot line-------------------------------------------------- ...................................................... -Am----------------�L�..... ..... Remodeling arAzor repairihc"sciribe):---- ........-------- 400. --------- .....40k ....•......0; ...... ---402A.4 ................................................------------------------------------------------------------------------- ............. —-- --_-----_ ------------ii ------ ------------ ...... - ------------------------------ ---------- I hereby certify that I hake Acepared thi's-apAcation and t4"at.the work will be done in accordance with San Joaquin County ordinances, State laws, and rules an 41regulations of the San Joiquin Local Health District. (Signed ------- A -------------- --------------------------------------------------------------------------------------------------(Owner and Contractor) buildings, etc., can 6e'-plAi6d on reverse side). ---------- = B)-y--:,. . .......A400f-_".'_1j....... PK--ioslol--------------------------------------------------------(Title)------------------------------------------------------ --------- (Plot plan, sho Ing size of lot, location ys;erVfn relation to wells, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------- ---------------------------- ........................... DATE-----------•-•-- t . DATE----------- ................................................... REVIEWED BY...........................---------------------------------- .. DATE----------- W --- DATE .. PERMIT ISSUED - -i ............. ............................................ Alterations and/or recommendaitiom-- .---•_•-_--__-. ----------------7-----_----------_._.................................................................................... ----------------------------------------------------------------------------------------------- ......------------------------------------------......................................................................... ------------------------------------------- ------------------------------------------------ ......................................................................................................................... ----------------- ---------------------------------------------- --------------------------------------------- ...-............. .................................................................. ------------------------------------------------- ------------- ------------------------- --------------------------------------------------------------------------------- FINAL INSPECTION BY----------------- Date---------------.- ..................... � �/' 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 EM-9 REVILED 6.59 F.F.00.2M 6.60