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APPLICATION .FOR SANITATION PERMIT Permit No. --_f� "" •" + ~ (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 applicatiori is made in compliance with County Ordinanc No. JOB ADDRESS AND LOCATION Owner's Name------- -------------------------------------------------- ----------...---- ---------- --. Phone- - t ----------------------------------------• ---------------•---•---•--•- ----•- Contractor's Name--•--�-••-------•--------•--�- ' ---------- -------_--------------- Installation ------------------------------------------- •----. Phone G Installation will serve: Residence E!� Apartment House ❑ Commercial El.—Trailer. Court ❑ [] Other . n .�nMotel Number of living units: ._.. Number of bedrooms Number of baths _"- " Lot size --"_-ff ,5 6 X"�. ------------------ Water Supply: Public s stem �/ ---------- y L� Community system ❑ :Private ❑ Depth to Water Table ` ft." - Character of soil to a depth of 3 feet: Sand ❑ Grave) dlLoam � ❑: Sandy ❑ Clay Loam ❑ Clay ❑ Adobe [-Hardpan ❑ " ©f ❑ D�FHA/VA: YeNew Construction: Yes No ' E]TYPE OF INSTALLATION AND SPECIFICATIONS: k Previous Application Made: Yes El No . .No [� (No septic tank er':cesspool permitted if public sewer is available within 200 feet.) ?' Tank: Distance from nearest well-----------------Distance from foundation __' No. of compartments = = Size-------------------------------- ." _ Material ------- -------------------------Liquid depth---•------f---- ---- -Capacity t __________ Dispdsai field: Distance from nearest weil_ istance from foundation__: 4-. * r Number of lines---------/---------- " Length of each line-- -- Distance to nearest lot line"_""-_"�_------ e g t ------ Width of trench. _e-- Type of filter material"_-S-_�� "� + r_ Depth of filter material----./-$ Total lengthe """." Seepage Pit: Distance to nearest well__--!�-OLu�.+ Distance . f ndation__. : 3 , Number of its.'""""--". / 5.�'._...Distance�o.nearesf lot line_.".__ _-- -_ P r /-i-----_ Lining material____`" -_ _-Size: Diameter-------- 3' Depth-_. -- �.`�-"------ Cesspool: Distance from nearest well----------- ".F Distance from foundation:_.--r "__�� ,.f ----.Lining material------------------------------------ Q ❑ 5�ze: Diameter---------- --------- -------- �-----;Depth -----------....-----' � s: � Privy:' ----- - -- - Liquid Capacify -------------------------gals. : - ---------------------Distance from nearest buildings----------- 'Distance to nearest lot line--i--__--'" -, - - - --------- ----`----w---------r+--.-------- Remodeling - ---- -."-_.". ------•---------- ., acr i emodeling and/or repairing (deseribe} _-----_---" ----------- ---------------------------------- ----- - -------------------•- re ce t that I have re are 1 ------ and rule and reg this s an licatiof San'-----------------------------orwill -.d n ---c --- n i ordinances, $t to la d that }he work will be done in accordance with Sap�Joaquin County Joaquin Local Health District. r (Signed) .. 4 - . ---------------- ------------= - ----- --=--- ---------------------I% % -•---------•---•-----•--------•-•------•-------- --- ----------- - --- - r and/or Contractor) cane a - = Title-----,"meq -----------( �-�4 " (Plot plan, showing size of lot, location of sys+em in relati to wells;,buildin s etc., can be laced on reverse side). 9,. p ti . FOR DEPARTMENT US`t ONLY +: APPLICATION ACCEPTED BY- ---------------- f ` _ r - -- REVIEWED BY DATE_:_).--.-- F --------- ------- --- ------------------- BUILDING PERMIT ISSUED-__-___-- "-_•"_ .0- - DATE =- ------ -- --- DATE.' F '-- 4 ► ---- Alterations and/or recommends+ions:-".___. -_ ._ "'' ' - e ---------------------•----•------- -. `„ --- ----------------------------------------- - -----------------••-------------------- -------•---- ---•-- •---------------- ------------------------ - ---------------------------------------------------------------------------------------------- --------------------- ------ INSPECTION-BY:.--::�. Date" /G' ,r L SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Ltreet Stockton, California814 North 'C' Street odi, CaliforniaCelifornie Manteca, California ��G Tracy, California 4-2M Revises 1.57 F.P.CO. l/ +