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A O APPLICATION FOR SANITATION PERMIJ Permit No. .. d............... u s. � (Complete m Duplicate) Date Issued ----- Application is hes _m_de to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is maden-,_ompliance with County Ordinance N�Z� JOB ADDRESS AND LOCATION____ -- ----------- --------------------------------------------------------------------------------- Owner's Name_.---�' -=---•-- ------ Phone-----------------------------_---- Address----------- ------ ---------------------------Address----------- /� ------------ --------- Contractor's Name - �Qt.t'3 'll Phone-----------------------•---------- Installation will serve: Residence ®"Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo�ttel'❑ Other ❑ Number of living units: ../-__ Number of bedrooms .-Z. Number of baths ____ Lot size __ .`d16_A----______________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No W3'- New Construction: Yes ❑ No ®' FHA/VA: Yes ❑ No R ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sepf Tank: Distance from nearest well________-___-___Distance from foundation-----______________.Material--_______________________-_-----________-__- — > No. of compartments--------------- ------Size--------------••-----------._..Liquid depth--------------------------Capacity----------------------- D1sp sal Field Distance from nearest well '_-'Distance from foundation.`_jP-_?'..__Distance to nearest lat line....r�____ Number of lines--------- ______ _____________ _ Length of each line-----,3a?_ ! __ ___________-Width of french------ Type of filter material__ ---------Depth of filter material-----------------------Total length-----'y �- -- -- Q- Seepage Pit: Distance to nearest well__`�1. '_=Distance from� fou)f}�dation__�Q_�t'.___.Distance to nearest lot line__,0---____- R?- Number of pits------/-------------Lining material:Cy_4z t-4__Size: Diameter_,f,.{_� p i Cesspool: Distance from nearest well_________________Distance from foundation--------------------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: ----------- w ------------ •------------------------------------------- -------:----------------------------------------------------- ----- ---------------------------------- ----------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------- 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 kand of the San Joaquin Local Health District. (Signed)--------------------- ----- - ---------- - (9wnerandfor Contractor) ----- ---- - - - By:----------------------------------- - ---------(Title)-----------07`v ----------------------- (Plot plan, showing size of lot,, a�ionf system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------ -- DATE REVIEWEDBY------ ---- ---------------------------- ----------- ------ --- ---------------------------------------- DATE-----------------------•---- BUILDING PERMIT ISSUED------------------------------------------ -------------------------------------------- DATE------ --------------- Alterations -------------- AI era ions and/or recommendations----------- ------------ --- ------------------------------------------------------------------------- " -1 �� d._ c ----------- •---------------------- -�--------------------------------- ----------------------------•---- -------------------------------- ---------------- ------------------ --- �j, FINALINSPECTION BY:----- ' ---- ----- --- ---------- -- Date----- - --- ------------------------------------------------------------ SAN -------- --------------------------- ------------- 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.