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i APPLICATION FOR SANITATION PERMIT Permit No. .__p_,_� -- (Complete in Duplicate) . � - � • Dat Issued --------- Application is hereby made to the San J aquin Local Health District for a permit to construct and install the-work Herein described. This application is made in compliance ith County Ordinance No. 54 JOB ADDRESS AND LOCA N. __ ---------------------- --�� Owner's Name__ . I�� --------------------------- Phorie Address---------------------------- ------ Contractor's ---Contractor's Name ` ---- -- ------ -------------- --••-- Phon Installation will serve: Resi ence Apartment House ❑ Commercial ❑ Trail r Court ❑ Motel ❑ Other ❑ Number of living units: __ _____ Number of bedrooms _--,___ _ �f _10)(11 21 y Number of baths _ Lot size ��- �- Water Supply: Public system ❑ Community system Private ❑ Depth to ter Table ft`�� Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam Clay Loam [] Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes El No TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or'cesspool permitted if public sewer is available within 200 feet.) S tic T : Distance from nearest well___.___________Distance from foundation___________________Material_____._____ No. of compartments-------------- ------Size--------------------------------Liquid depth---------------- ------- Capacity osal Fi Id:A Distance from nearest weil_12_�_'_Distance from foundation____ 0 � Distance to nearest lot li. Number of linesef ---------- ----------------Lenpgth of each line__- - ----��---Width of french..-_---�-`,--------------------- T e of filter material_ --_De Depth of filfier material -._ _______._._Total length___��_/_�_____ __-__________________ S age itt Distance to nearest well__/_a•�_.....Distant from foundation--_1 Dist nce to "est lot line__._ -4 f �� Number of pits.__-----------------Lining mate ria l_ `► 'r , -��. Size: Diameter.__ _,._._._ _ De th _ Cesspool: Distance from nearest well-----------------Distance from foundation--------------_-----Lining materiaR ___.__.-_______..__._-_-_________- ❑ _Size: Diameter--------------------------------------Depth-.-------------------------------------------------Liquid Ca acitY_..---------------- ---------------------------- �p Privy: Distance from rearest well____._'__-_--______'_________________________Distance from nearest building.___ ---------_--------------------------❑ Distance to nearest lot line------------------------------ ------------------_________-__-__- I� Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------- 1 --------------------------------------••------- ----------------------------------------------------------------------------_1----- ---------------._-------------------------------- IM. --------------------------------------------------------------- :I 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. - �I (Signed)-------�= --�-- -�� ---- ---�=:rte�> �,!!}.[�t��-�-1--------------------- - - --- - ----------------- Contractor) ��-y,� i gY: -- can)Title)_ WIj/ /L (Plot plan, showing size of lot, location of system relation to well buildings, etc., be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- --- ------------------------------------------------------------------- DATE---- "X-� - !-t- I REVIEWED BY - -----------•--- DATE------------------•--'�� -- -- ------------------ BUILDING PERMIT ISSUED------------------------------------------- -----------------------_-------------- ---------------•-- DATE----- 3' Alterations and/or recommendations:__________._ 9i: -- - ---------------------------•- ----------------------...--------------------------------------------------------------------•----------------••-------•-------- -------- �M-- ------------- -------•-------------------------- ----------------------------------------------------------------- - --- ---------------------------------------------------- I i - -- ------------------- FINAL - - --------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 ES-9-2M , Revised 1-57 F.P.CO.