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r _ FOR OFFICE USE: - ----------------- _ -------- APPLICATION FOR SANITATION PERMIT Permit No. :__ll`, .� --- ---------- -- -- -------------- {Complete in Duplicate} Date Issued ._/�� I This Permit Expires 1 Year From Date' Issue Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This a pica ion s�ode co i�an-c with ounty rdinante l er 9.�p -�- �r C f/ —��"`�r�--- acr� ( ]z.�-cl- ------ -------- f---•- _ JOB ADDRESS AND LOCATION_______.__ _ �-.__---- t-4------ _ Owner's Name-------- f d.LCI: f -' ------------------------------ Phone� e�-- a �--- = ----------------- - ----- -- -- - ------ Address------..._ -----------•--•---------- r -•------------------- Phone----------------------'---------- Installation Name--------------- .E`d - -------------------- -------- - Installation will serve: Resident Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: --j--- Number of bedrooms .-_._.Number of baths _j.__ Lot size /Z--- ----------- . Water Supply: .Public.system ❑. Community system ElPrivate K Depth to Water Table _ �I ft. Character of soil to a depth of 3 feet: - Sand ❑ Gravel ❑ Sandy Loam ❑ Qay Loam ® Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes No ❑ FHA/VA: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from,nearest well__ � Dis#ante from foundation_--__ld_-_______.Material---- e!'G-a --------------- No. of compartments---------c ---------_Size----Z4/Y_-�-0------------Liquid depth----141t.--S---------Capacity---/2Q!P_---- 1 ' _. ! Is--------- p __Distance from foundation-- to nearest lot Dis osal Field: Nlumberr ofol nese st Cell.-. '6-_* Length of each line�..'r _P -----Width of trench._r ________________________ _Type of filter material_-- !- Depth of:filter mater ______ ____- ial �__R- -� Total length______J: �y -- ------------------- Seepage Pit: : Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line_.__--_.______._- 4` ❑ Number of pits----------------------Lining mater'sal---------- ------------Size: Diameter----------------------.Depth---------- ------------------._.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material _._______._-.-___.___--__________ ❑ Size: Diameter----------------------- ------Depth------------- --------------------- ------Liquid Capacity- ---------•----- ---------gals. w__ - - _-"Distance from nom`sorest.builain - - -' Privy: Distance frorri.nearest well - g ❑ Distance to nearest ]of line------------------------------------ ----------------------------------------------------- - - -------------------•---------- ' - -------- ------------ ------- -- -- - -- '-- •______ - + -R--emodelin-4g nd/oYr _r-e• pair-i-n-g-- {de-scir•ibe):-_h---� � ---- ____ ---------------------`r4J...�.1�� --'-_ _--paw ------------------ I ---- `------------------"--------- ------___------- -----___---- --- ------ -- ------------ ---------------------------------- -------- ------------- - --------- - / ----------------------------------'•---------------------------------------------------------------------------------------------. I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules'and regulations of the San Joaquin Local Health District. ---------------------------------------------------------------------------(Owner and/or Contractor) (Signed)--, i . k' - ------------------ ------------------------------------ --(Title)-------- ---- BY' - - - (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY--- --------- ------- - ----------- -------------------- --------------- -------------------- DATE----------------- - REVIEWED BY-------------------------------------------- DATEer � -------- ---------------------------- BUILDING PERMIT ISSUED---------------------------------.--------- �- -- ----------------------- DATE----------- Alterations and/or recommendations-------- ------------ ------------------------•---------------•---•-----•----------•----- -------------------------------------- ------------------------- ---- -------------------- t ---------------- ---------------------------------------------------------------------------------- ---•-•--------'-------•--------------------------------•------- ----- --- It -----------------' - ------ - ------------ FINALINSPECTION BY:..----- ------- - � Date-------------- ----------------• ------ ------------ ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 16o1 S.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California t- ES 9 REVISED E3-59 3M 3-'63 F.P.0 D.