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OR OFFICE kJSE: -------- ------ --------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .................._.--� --------------------------------------------------------- (Complete in Duplicate) _________________________________________________________ "� This Permit Ex fres 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Healfh 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 LO ATIO --------V -� -------- _ ---- ---------------------------- Owner's Name------- �� ,� �LI_.- •: --e X------=---•----------------------- ------------------------ ------ phone------------------------------------ I 7 Address-------------'51-L —Al � �/..... ,/Gz�, ,�'. .._... Contractor's Name._---- afL_o...._- ............... [3 Installation will will serve: Residence?❑ A artment House ❑ Commercial ❑ Trailer Court ❑ Motel [3Other ❑ Number of living units: _:[___- Number of bedrooms __umber of baths ( Lot size --------- -D------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table — ft. i Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ Previous Application Made: (If yes,date____________________) NoZ I New Construction: Yes ❑ No ❑ FHA/VA:IS ❑ No ❑ a t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer ii, available within 200 feet.) r tic nk• Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------ . ? No. of compartments--------------------------Size----------------------------_Liquid depth--------------------------Capacity-__ Disposal Field- Distance from nearest welL ./,0----------- ling .,.5 from foundation __.___.Distance to nearest lot lin ,eF_f_ 5 ytW-Number of lines____________ _ --------Length of each line_____ ----Width of trench.__.e_�/__ _ a Type of filter material__- Depth of filter material-----_1/�-_______Total 7 - Sea Pit: Distance to nearest well_-/k L)w _Distance from foundation___._/Q---r..Dista+cp to nearest lot liine___4---------- Number of pits---.___-----------Lining material___- flel" Size: Diameter__.6,�_. -------- Depth__1�____------------------ Cl: Distance from nearest well_________________Distance from foundation---.----------------Lining material-------------------------------------- Size: Diameter-------------------------------•----- Depth----------------------------------------------------Liquid Capacity----------_-----••-------gals. Privy: Distance from nearest well------_----------- ------------------------------Distance from nearest building_____---_______________________-________-- 5 ❑ Distance to nearest lot line--------------------------------------------------------------------------•-----•...._---. -----•---•----------•---------------------------- Remodeling and/or repairing (describe): _-- � __ ____________________________ 4 - -- -- - --------------------------------------------------------------------------------------------------------- ------------------------------------------------------------•-•----------------------------------------------- L I hereby certify that I have prepay applica+ion and that the work will be done in accordance with San Joaquin County ordinances, State laws d ru an regula ' ns of the San Joaquin Local Health District. 1 (Signed)----------- -- ----- :. caner and/or Contractor) By:--------------------------------------------- -- -- -•-- -- -- --------- -- ----------(rifle)------- 4Z�� - (Plot plan, showing size of lot, locafion o stem in relation to wells, but ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ------------------------ DATE---- f ' _ f----------------------------- REVIEWED ------------------------ -REVIEWED BY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ j BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:------------:----------------------------- -----•-••--•--•-------------------------------------------------------------------------------------•..........------ -------------- ------- = - mr;A- ---��64- -------- �c t. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ ; FINAL INSPECTION BY:---------- Date-------- R _r. 1r��t----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT k 130 South American Street 300 West Oak Street 124 Sycamare Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9.9 REVI9E0 9.59 F.P.00.2.6-60 k 5