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APPLICATION FOR SANITATION PERMIT Permit No. ._�_�_�_Cr__� (Complete in Duplicate) 7 Date Issued ____/y�� 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 ,Or)dinance No. 5". JOB ADDRESS A DLOCATlON____3s5___!______W-_____- - ` -- -------------------------------------------------------------------------------------------------------- Owner's Name -------- -- Phone------------------------------------ Address---_-------------- Contractor's Name___________-______----------------- - r I ------------------ ----------------- --------------- ----- Phone----------------------------------- Installation will serve: Residence-j6_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - - _ Number of bedrooms --73- Number of baths ____I__ Lot size __ 4O--_X_/11A---------------------- I Water Supply: Public-system Commuriity system ❑ -Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E❑ Adobe�?kHardpan 0 Previous Application Made: Yes ❑ No h New Construction: Yes [f No;�_ FHA/VA: Yes ❑ No� TYPE OF INSTALLATION AND SPECIFICATIONS: �v (No septic tank orcesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_.! "__Distance from foundati _ _A0______-Materia` -- -------------------- No, of com artments_-_---------------Size__-_7____ -Liquid deAth----------Iy _ _Capacity Disposal field: Distance from nearest It Distance from foundation__ _ Distance to nearest lot li e__ �` Number of lines_________-___ _ _______ __ Length of each line____________ __�_______ Width of trench.__ . ____ --------------------- Type ___ _____-_-_____-- Type of filter material____ Depth of filter material --__;;W_Total length-----��-0 - - -- ---- - - - --- Seepage Pit: Distance to near t well-�� _`_____Distance o foun ation----4761-------D;stanc`to nearest lot line____ +,` Y - VJ Number of pits- - ing material _____ ___ x_ i Diameter__, ____Depth ___$ aY 0 - N Cesspool: Distance from nearest well-----------------Distance fro foun tier---------------.----Lining material____-.___________________________- ❑ Size: Diameter-------------------------- -----------Depth-------------------------------------------------•-Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-_--------_--------------------------------------Distance from nearest building----------_--------_-______________-____- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------- - Remodelingand/or repairing (describe)------------------------------------------------------------------------------------------------- -------------------•---------------------------------- -------------------------------------•------•----------•--,---------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------•------------------------•-----------------------•--------------------------------------------------------------- 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. (Signed) - -" ---='^'----------------------------------------------------------- ------------------------(Owner and/or Contractor{ By:------------- rn(/ ---------------'-------------------------------------------------(Title)---------------------------------------------- ----- (Plot plan, showing size of t, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DFPAR MENT USE ONLY APPLICATION ACCEPTED BY------------ ---- ------------------------------------------------- DATE------------------------- -- ----------------------------- --- --- ------- - - REVIEWEDBY------------- ------------------ -- ------- -------- ---- - --- --- --- - ---------------------------- DATE------ ------------ BUILDING PERMIT ISSUED--•---------------- --- -- ------------- -------------------------------- DATE------------------------------------------------------------- ------ --------- -------- Alteratio and/or.recommendations:--- -- -_- ----------------------- ----- ___--__-- - - ------- - - - -- Q - = ' - ------=--------------- --------------- --- ----------------------------. �---------------------------- - - ---- ---------------------------------- ------------------------------- --------------------------------------------------------------------- FINAL INSPECTION BY:--1 __._-- --<__-y_6 -_---------------- Date------ - -`--�-- SAN J AQU1N 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 VP,CO-