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' APPLICATION FOR SANITATION PERMIT Permit No. .__ 5_ in Duplicate) (Complete p } ba+ei-lssued'----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 County Ordina No 49. JOB ADDRESS AND LOCATION______O)�.1___l__1.------- , _ Owner's Name------- / ---- --------77---- -- ---------- Phone-----------------------•------------ Address-------------- / ---- -- ---- -- - -------- ----- - - �--------------------------- Contractor's Name `�- �--------- -- -- J - Phone ----------------- --------- Installation will serve: Residence ❑ Apartment House commercial ❑ Trailer Court [❑ M,otteell O Other El Number of living units: _ __ Number of bedrooms _x--- Number of baths _ _ Lot size __ 7C.,1__�10a---------------------------- Water Supply. Public system ❑ Community system ❑ Private ❑ Depth to Water Table _'9P ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�Hardpan ❑ I Previous Application Made: Yes ❑ No P�' New Construction: Yes ❑ No FHA/VA: Yes ❑ No g-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) eptic ank: Distance from nearest well__________ _______Distance from foundation___________-______-Material_______________.________.______-_-_-_--_________- No, of compartments______._________- -----Size---•-•-•--------------------=---Liquid deP.t�--------------------------Capacifiy...-------------------- Id. 1 Distance from nearest well_. e`'.Distance from foundation __l�_____._Distance to nearest lot line____Y! � ` Number of lines--------- ength of each line_____,. ��_______.Width of trench.___ y.__.______._ Type of filter material_/�_ epth of filter materiaL_ 4 ______.Total length___._ P--- ...�_.Distance to nearest lot I'ne__�er Seepage Pit: Distance to nearest well--- 6istance f om �f 'dation___. }� Number of pits_____ ____________Lining mate ria l__/ !C------Size: Diameter__y `I_____.Depth____. _---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- 0- _______----__._______------------_❑. Size: Diameter------------- ----------:------------Depth--------------------------- --------------------Liquid Capacity----------------------------gals. ,Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------:----------•----------------. ❑ Distance to nearest lot line--- ------------------------------- -- ---------------------------- --------------------------------------------------------------------- Remodeiing and/or repairing (describe):-------------------�,---- -- ---- - - - - ------------- ------------------------------------------------ } --------------------------------------------------------------------------- - -- - - ------------------------L_______--__-_____------------------------•---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -•------------------------------- ------------------------------------------- ---------------- ----------------------------------------------------•--------------------------------------------------------- " 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're�qulgitlons of the San Joaquin Local Health District. (Signed)----------- 44 �'" (�r Contractor] ------- - r------------------------------- Title . --------- ------ ---------------- (Piot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR P EPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -------- ------- ------------------------------------------------ DATE-------------q- ------------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------•---------------------------------------------------------------------- DATE---------------------------------------•--------------------- Alterations-and/or recommendations--------------------------------i -------•---------------------------------------------------------- ----------------------------------------•--------------------------------•----------------•---•--••--•------------•-----------•-------•------------------- -----•--•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -7_�D7- FINAL INSPECTION BY:------ ---------------------------------------- Date--- ----------------- - ------ ----------- ----------------------------------- 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 J ES--9-2M , Revised 1-57 FY.CO. 2