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FdR OFFICE USE: ................ A__-____............................ APPLICATION FOR SANITATION PERMIT Permit No. ... . (Complete in Duplicate) y ------------------------------.. - I G ..............._..._..._.___....... This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health Dist ricf for a permit to construct and install�thre work herein described. a This plication is made in compliant with County Ordinance No. 5 9 OL -5 ^ 136. �� JOB ADDRESS D LOCATION .1�--- ------------•--------- --__a�......_..-- ------------ ----------------- r Owner's Name.(--h- = Phone...................................... ........................... ............. Phone----------------------------------- Contr ictor's Name-----.-- .__--. _--• -- Installdition will serve: Residence Apartmen House [D Commercial [3 Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: J.... Number of bedrooms... Number f baths .- Lot size _. �2 ��__________________•..-_-.- 1 Water Supply: Public system ElCommunity system El Private Depth to ater Table -------- ft. Charmer of soil to a depth of 3 feet: Sand Q Gravel E] Sandy Loam Clay Loam F] Clay[I Adobe❑ Hardpan❑ PreviO[ Application Made: (If yes,date... .............._.) No E] New Construction: Yes El No ElFHA/VA: Yes ❑ No E] k TYPE F INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well...._SIO.....Distanc�g� fromqq foundation......E_G.........Material..................... .... ................... r1e No. of compartments...._.. _-._.Size!�la�X/.�/ _�:�_Liquid depth..._.✓�.�.._____._____--Capacity._/--ce!!_8#.X i % (� Dispo Field: Distance from nearest well._. 5'9 ...__Distance from foundation__ Lt�__..._._.Distence to nearest lot�ine__ ____________ Number of lines_.__.__._.._. j Length of each line-------P _.._-._ -----.Width of trench_._.?__-__-._�............. Type of filter material._ �rd,-,....Depth of filter material.....y�f$..........Total length------r __________________ Seep.1ge Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits- -------------------Lining material.......................Size: Diameter............. ........Depth.._.............................. 144 , Cesspool: Distance from nearest well........._.......Distance from foundation....................Lining material................................ _-_ El Size: Diameter..... --•----- .............Depth-------------------------------------------_-----Liquid Capacity---_-------- -•----gals. Privy: Distance from nearest well___________________...... ------................Distance from nearest building__--.___._____-__-_.______-_____----_--- Distanceto nearest lot line._...................... ..................___-----.._..,_..--•----.__-----•--..-_--•--•...:............---------•..._. . . "4 Remeling and/or repairing {describe):------------------------•--•._...._. ....... -•--------•---•••------•-------••-----..---------------------------------............................... �. ._.._...--•-•••••-_......................... -•----•-•-----•---------..................................-----•-------•-•-.............................•-•-••------•-.---- •-•---_____-_-•--------------------------- •----------------- -•-•-•--------------------------------•--•--•----------•-••--------- -- --•---------------------•---•--.._-----•-•---.....-•-•--•--•----------...........-••---•----••-•-•-�------------------------------------------- -----------------•-----------..._..-----.... -- ....-__.... I�hereby certify + I have prepared this application and that+he work will be done in accordance with San Joaquin Coun ordinances, State I S. rules and re of the San Joaquin Local Health District. (Signed)-------•• --- ---- . { .---...... ti7wd/or Contractor) R B ' .................... ......(Title)------------- ----------------•----------- -- -..__..-._._ (Plot lan, sh size of lot, location of syste in relatiol+ wells, buildings, etc., can be placed on reverse side). _ r t FOR DEPARTMENT USE ONLY A P CATION ACCEPTED BY.__ "�'--. •• .. .. ........................................ DATE_ _:.Z ._-.4 ___..........__.. . ...... REVIEWEDBY.......................•---•-------•--........_.... -- ........................ ------ -.---............................... DATE...................................._..._._.._.----•-...._.. BUIL61NGPERMIT ISSUED................----------------- --------------------------......._--------•--......--•---------•. DATE..................................... -- --- ---------- Altetions and/or recommendations:...................................................................._._..-------•-...-...---.-_..-_.---•-•--....__._.____.____..._--•-------•----------..._.... ..........................._... ••--••-•-•-•-•--...............................................---•---•-•-•---•--...__._...__......_._._._.._....._._............................................................. .....__..._I-- - .................... ......•----•--•-•-•----.__....------ ------ -•---•-••-•-•-----•-•---• ------..------...------._.....-..--.... --------------------------------------•--•-••. .. I .._..----•........................•---•------•------._...----• ................ M .. .......................... . .............................•-----.... .......... FINAL INSPECTION BY: /`'! / ........._.. Date.....Q....: .b...'_. .Y.__----_-•-- SAN JOAQUIN LOCAL HEALTH DISTRICT 16o1 E.Maxelton Ave. 300 West Oak Street 124 Sycamore Street 205 Wast 9th Street ~ Stockton,California Lodi,California _ Manteca,California Tracy,California Ca ,9 strvisco a-s9 3M 3•'463 F.P.Ca.