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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / This Permit Expires 1 Year From Date Issued Date issued ___ ��1.�� 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 Cou_rity Ordinance Nc2p, J , JOB ADDRESS AND LOCATION__ ..... I .. .-...... f / <--- ---- - 1 ------------------•----------------- .. Phon .. Owner's Name---------------------.-------•r--- -.11rl,_� -�-f-- -------------------- -- -- ------ - Addressm - ------•-•---------------------------- �+ Y �� ----- Phon -., Contractor's Name__-_�-1------------------- Installation ____ -��t- ' _-_____________ ______ _ q Installation will serve: Residence AApartment House,0 Commercial El Tr Court L] Motel ❑ Other [I- .r Number of living units: __ .___ Number of bedrooms . Number of baths _____._ Lot size _ff_ _. - V. Water Supply: Public system <Community system ❑ Private ❑ Depth to Water Table C�_�` ft. Character of soil to a depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado - Hardpan ❑ Previous Application Made: Yes ❑ No.Al-New Construction: Yes ❑ No-1FHA/VA: Yes ❑ No ❑ 41 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e tic T Distance from nearest well-----------------Distance from foundation--------.----------Material--------_------.__---_.------_----.--------_----. No. of compartments -----------Size .Liquid depth-------------------------.Capacity- ------- osal Distance from neares well._Distance from foundation..-J-6--0-----Distance to nearest lot line-_--- ,,I Width of trench-----5 -,- ---!'------- -- Number of lines--------- "- Type _____._ -_Length of each line___ ._�_____ Type of filter material- Se __ __ __ �- --Depth of filter material__.___�� _Total length_._ _t�'___________________/ epa e Pit: Distance to nearest welLJAO-AL3----Distance fromf undation---•-f_Q..._--Distance to nearest lot line__---.-- Number of pits.-.I-----------------Lining material... - Si, e: Diameter____ _ ��----Depth— -------*__._._.__.... a Cesspool: Distance from nearest well-----------------Distance from oundation--------------------Lining material----------------------_-.------_-__. ` ❑ Size: Diameter--------------------------------------Depth----•-----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well----------------------------------.-------_------Distance from nearest building---------------------------------._------- ❑ Distance to nearest lot line------------------------------ ------------------------------•-------------------------------------------------------------------------------- Remodeling and/or repairing (describe):---y- ---- -------------- = ----- ---------••---- ---------------------------------- ✓ \ ---- - -- - ----- --- __ -------------------------- ------ - a ---- ----------------- ••-------------------------------- ----------- --------------------------•---------------------------------- l --------------------------------------------------------------------------------------- I hereby certify.that I have prepared this application and that the work will be one in accordance with San Joaquin County l ordinances, State laws,.`al�essf�a(n�d regulations of the San Joaquin Local Health District. I (Signed)---------------= '�"' I 'r' '" ----- ------As. -- ------- --------- --------------------- ontractarJ SEj-nC Tip NK SERVICE Title x I BY �935E:1lillner�ll/e •-alt &Mat----------- { ) - A (Plot plan, showing size of lot, location of system in relation todings, etc can be placed on reverse side). FOR DEP ENT USE ONLY APPLICATION ACCEPTED �. = - -- -=-- -- ---------------------------- DATE' 91 - REVIEWEDBY----------------------------- ----------------------- ---------------- -------------------------------------- DATE----------------------------------------•------------------- ' BUILDING PERMIT ISSUED----- --------------- _ --- � -- ' DATE--------------•-------------------------------------•------- ------ -- _ -Alterations and/or recommendations:._�____.__...► h- ----"---P-A--- ---,e��+-------=C) �---------Q- Q-------�---- ----------- ----------------------------------- ----------------------- ----------------------------------•------------------------------------------------------------ ------ ---- ---------------------------------------------------------------------- ---------------------------------------------------------------------•----------••------------- ----------------------------------------- FINAL INSPECTION BY:----- ---' ------------------------------ Date------G- 7. -CQ_-f------- -------------------- t_: 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 Es-92M Revised 8-'59 F-P.Co.