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FOR OFFICE USE: _ -------------------------------------- ------ APPLICATION FOR SANITATION PERMIT Permit No. ... ..-.--.. ... ... -- --------- -- -------- --- --------- -- ------------ (Complete in Duplicate) -------------- This Permit Ex ices 1 Year From Date Issued Date Issued ______ __ ------ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein escribed. This application is made in goSnp�nce,mwith unty r inance No. 549. JOS ADDRESS A D �OCA�/TION ��//gip. ' [� .. .. -- ��f� t'c. a5a -t.,4W Owner's Na - - Phone ----- ---- --- --- -- --------- ------------- ----- Address ;f� �. I C = = ------------------------------------------••----------------....... t de Contractor's Name -ems= -�� .�fh -------------- ---------------------------------- Phone................................... Installation will serve: Resiclenc�,p Apartm nt House ❑ Commercial ❑ Trailer Court Rr_`Mofel ❑ Other ❑ Number of living units: _ ____ Number of bedrooms -------- Number of baths ________ Lot size ------ 6J fes_________________________ Water Supply: Public system ❑ Community system ❑ Private ��Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sapdy Loam lay Loam ❑ Clay [❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes � No ❑ FHA/VA: Yes ❑ No r ---TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) `• Septic ank: Distance from nearest well---nF ------Distance fromfpundation....K----------Materi ��al_-_64_-___r________________________________ No. of compartments_.--__4----------____Sizey__%__��>Q__X_�_-.Liquid depth_.-__-��'_-_---.-------_---Capacity__/- / 1 V ti Dispos field: Distance from nearest w Il-___5______-__Distance from foundation___-/_Q--_.-_-.-_Distance to nearest lot line.________--- Number of lines___-----_ __ _ __________ Length of each line___.__„j`�'0___ ___-_Width of trench______-----.--___-______._ Type of filter mate riai�# ._ _ k Depth of filter material-----_/x----------Total length-------1 Q P__ _________________- Seep e Pit: Distance to nearest well---- _...-. Distance from f undation___--/....___.Distance to nearest lot Number ofpits----__�-------------Lining material--,��. �- Size: Diameter- -----��-1"-1" _--Depth--,--,;? ------ Cesspool: Distance from nearest well_____,-----------Distance from foundation--------- --.------ Lining material---------------------------------- u ��❑ Size: Diameter--------------------------------------Depth----- ---------------------.:--------------------Li qid Capacity- - - --- ------•---gals. Privy: Distance from nearest well-------------------------------------------------Distance fromynearesf building-----------------------.________-_-__.--_. K ❑ Distance to nearest lot line---------------------------------- -------------•---------------------------------------------- Remodeling and/or repairing (describe): ---- ---- -------------- --------------------------•--------•------------------ -------------------------------------------------------- w r - - -- - --;-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- ------I----------------------------------------------------------------•----------------------------- ---------------------------------------------------------- ------•-----•------------------------------- Vl -------------------------------------------------------•-----------------------•---------•-------------------•--------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquin County ordinances, Stat laws, and rules and regulatio.s the•San. Joa in.LocaI Health-District: r / e Si nod _______-`, caner or Contractor) BY=-------- ------ --"a----tin 4relafio --------------------------------(Title)-------------------------------------------.---- ------------- (Plot plan, showing size of lot, location of syswells, buildings, etc., can be placed on reverse side).1 4Z FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----------------------------------------------------------- DATE-- REVIEWEDBY-------------------------------- - ------ ------------------------------------------------------------------------------------ DATE------------------------------------ BUILDINGPERMIT ISSUED--------- •----------------------------------------------------------------------------------------- DATE------------------------------ ------ --- ------------------- Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------_---------------•-•-------------------------------- ----------------------------------------------------------------------------- - ------------------------------------------------------------------------------------- ------------------------------------------.------- ------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------•------------------------------•------------------------------------------------------------------------- --------------------------------------- --------------------------------------------------- -- ---------------------- -- ------------------------------------------------------------------------I------------- -----------------------------------------•---------------------------------------------- FINAL INSPECTION BY:-- AZ w - Date- -- �1 -- -------------- - - - - ---.------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISEP 13-59 3M 3-•63 F.P.CC. ,,, Aw oo59- I-zo- 02