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: �.... -------- / �:S g APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _____ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein.described. This application is made in compliance with County Ordinance No. JOB ADDRESS AND L ATION � °1.-_ ------(�i -------------------------------------------------------- ------ IOwner's Name-------------- -------------------------------------------------------- ------------------------------ ----- Phone-------------------•--------------- ------------- Address - --------•--------------------•------- ---------•---•----------------- Contractor's Name---- 7 ---------------- Phone-------------------------••-------- t Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---4- Number of bedrooms J--- Number of baths '-_ Lot size -'--- ------ Water Supply: Public system [:1Community system rivate [IDepth to Water Table __,*0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Z?' New Construction: Yes g�-No ❑ FHA/VA: Yes 4�0 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ailable within 200 feet.) r (No septic tank or'cesspool permitted if public sewer is av Septic T on k: Distance from nearest well in---15istance from foundation___Z�______.M terial----�l - ---- ----------- ---------- __ Liquid depth _!_______Capacity.___ 3 No. of compartments Size- e ` .r .- Disposal E' Id: Distance from nearest well _ 71ADistance from foundation__41 _`___-.Distance to nearest lot line__ ..__.:___- Number of lines-------- -_ _ Length of each line-------- �j f� Width of trench__ ___ Li----------------- e of filter materiall Depth of filter material---- -- ----f--Total length- ------------------------------ Type 45eepage it: Distance to nearest well_-",(l!VIr/ _Distance from fo ndation___Z�___.___.Distance to nearest lot line__' r______ Number of pits._.___`-"---------Lining material:_ Size: Diameter_____� .___Depth_-- _ _________________ l 4 Cesspool: Distance from nearest well-----------------Distance from foundation------ material____-_--_-- -____________:_______- Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------- - ' ❑ Distance to nearest lot line-------- ---------- ------ ---- ------ --------------- -- ------ ------------- •-------- Q; Remodeling and/or repairing Idescrii�e): ---------------------------------------- r -- --------------------------------------------- 3 ----------------------------- -------------------------------------------------------------------------------------------•-•--------------------------------------------------------------------------------------------------------------------- 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, a rules and re I tions of the San Joaquin Local Health District. [Signed) -- - --------------- ---- ---- -------------------------------------------(� Contractor) ------------- `-------------------------------(Title)------� ----------------------------- I (Plot plan; showing size of lot, location of stem in.relafion to wells, buildings, etc., can be placed on reverse side). w� FOR DEPARTMENT USE ONLY APPLICATION ACC PTED BY_(-:' --------- DATE_�:_ --------------------------------------------------- 1. REVIEWEDBY------------------------------ -------------------------------------------------------------------------------- DATE----71-1 L-------------------------------------------------- BUILDING PERMIT ISSUED--------- ------ DATE-------�-�'�--------------------------------------------- - Alterations and/or recommen�ation : C --;X--- -1 7 '.. r+ �.�.---- -- ----------------------------------------------------- ------------------------- ------------------------------------------------- -------------- ------------ ` Date_.._ ---- -` --- FINAL INSPECTION BY:_.----- ---- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M . Revised 1-57 F-P,CO. !�