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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ------------------------------ ------ - --- --- ---------- This Permit Expires 1 Year From Date Issued Date Issued __- //� Application is hereby made to the San Joaquin Local Health District for q permit to construct and install the work herein described. This application is made in compli nce ounty Ordinance No. 549. JOB ADDRESS AND LOCATI ? t✓__. � k _ � , Owner's Name------- =,"�F" / - - Phone-------------------------- Address----------- Address------------ ----- � /.--- -----------• -----------"----------------•--------------------- Contractor's Name d--� ......... -- --••- ----------•--- Phone----------------------------------- Installation will serve: :Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___-____ Number of'&droom's� -___ .Nu nU6r of.baths -_ _ Lot size ______ -------- ffff --------------- 'Water Supply: Public -system E] Community system ❑' Private Depthrcto Water Table___.�___ft:"�" Character of sail to a depth of 3 feet: : Sand_0 Gravel ❑ Sandy .Loam ❑ 'Clay Loam E[Clay ❑ Adobe ❑ Hard pen ❑• I Previous Application Made: (if yes,dat�_'------:_ ____.:_-) 'No ❑ 'New ConstiuctiontYes-❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:: i R` (No septic tank or cesspool permitted if pub[6,sewer is'available within 200 feet.) ' I Sep#ic ank: t nearest -well_ / f t /_01- -..Material Noofcompartme ts- �\ deph � " """ Ct"y__ Dispos Field: Distance from nearest well___ --_ !Distancefrom foundation-----"f_12__/__-Distance to nearest lot lines-(_._ ______ Number of lines___i_." _ _ __ iLength of each line________f_C2_Q-_--______.Width of trench-.-. " , - t5 7 Type of filter material____ -___Depthrof filter material------ ___ _-___Total length---:_-"�-""v" " ------------------- Seepa Pit: Distance to nearest well f_ ___�Distance fr Qndtion________�O__ Distance to nearest lot line----- (� s ll t p ---_-- Lining material - ' ze: Diameter----,-- 3"--Depth-- --'-S------------------- Cesspool: -------- - � Number of ifs':' _ ` Cesspool: Distance from nearest well-----------------Distance f•ro,m foundation__--__-___.___-___.Lining material------------------------------------- 0 Size: Diameter------ -------------------------------Depth--------------: Liquid Capacity gals. Privy: , Distance from_nearest well---------------I---------3`_;_____-_-_____{_. Distance from.nearest built}ing_____---____-________-__ [] Distance to nearest lot line-_-____.-.-sem... __:.___`___-.-______"_'`--"_""""____-•""__-_ ------------------------------------------- - Remodeling and/or repairing (describe)------------------------------------------------------------"••_!________.""_"_ i ------------------------- ----` r ---------------- '7_Y. " ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la s, and rules and "regulations o11�1 n Joaquin Local;Healfh District. r (Signed) - -----------= ----------- ----------- - ---- - -----------f-- --------- ------ w and/or Contractor) r t �. �"— By: r --- - -- - -- (Title} : _;c(Plot plan, showing size of lot, locationf system in relao ..to wells, bu ings, etc., can be placed,on reverse side). -- I - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED-BY_ REVIEWEDBY---- ----------•---------- ---------------------------------------------------------:------------------------------------ -- - DATE- - ---------•"------- BUILDING PERMIT ISSUED.-----------------'--------- ------------- --- -------------------------------------=-------- DATE-------------- == Alterations and/or recommendations:-_-____-___-_. --------------------------•---•--------------------•-------------=------------------------------------------- ------------------------ ------------------------------------- ------------------------ -------------------------- ---------------------------------------------•------------------------------------------------------------------------------------------------------------------------- ------•-------------------------------------•------•-"---"--- ---------------------------------------------------- - ---------------------------------------------------------- FINAL IN BY: ------------------ Date- 1 -------------------- SAN ----_---_'_----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 B-59 3M 3`663 F-P.CO.