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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) f This Permit Expires 1 Year From Date issued 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 application is made in compliance with County Ordina c JOB ADDRESS AND LOCATION ------- ..�.�5�_ , d es - "0 -2-1/ Owner's Name_, --_. ----------------------------- Phone � Address------------------_- ,,, �f. Contractor's Name-------------• i -------- --------•--------- -------- Phone_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units --/-- Number of bedrooms Number of baths /__ Lot size .-- --Q_ --- -----��-- - ----------•---------- Water Supply: Public system ❑ Community system ❑ Private gr'6epth to Water Table #_�o ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] "Clay Loam ❑ Clay ❑ Adobe [Hardpan I -] Application Made: Yes E] No [ New Construction: Yes FA -l" No I—I FHA/VA. Yac n Mn h TYPE OF INSTALLATION AND SPECIFICATIONS: Septic Tank: Distance -from nearest well__ _ ___ Distance from fou cl 200 feet.} No septic tank or cesspool permitted if public sewer is available wit dation__.__-/_Q_____-.Material___ gel .I. __________ _ [� No. of compartments--------------------5ize____.S _ .. .(a ---Liquid dep`h-_ 573- '----Capacity._"/. 1,,5— Disp—osa/l Field: Distance from nearest well_, -P_______ -Distance from- foundation... 14j,-1 --- to nearest lot Number of lines___ -_3_:___----___ Length of each line_6Z/__--� ,P41_VVidth of trench_ __ i� Type of filter material__, I_ _Depth of filter material__- _:__ ------- Total length ------- nce o nearest well"/�1fJ_�._____Distance om f ndation__--_____- Distance to nearest lot line___S______ rjiy ee a rf: De Nlumaberr of pits --_ T-_---------- Lining materialQ __-Size: Diameter ___________Depth_-__. __.______________ p g Cesspool: Distance from nearest well_________________ Distance from foundaf;on--- .---------------- Lining material --- .__________-❑ Size: Diameter---------------------------- .. _ Depth -- --- ----------Li Liquid Ca acit____.____._ WY------- -------------• -----gals. Privy: Distance from nearest well__________________ ______________________________Distance from nearest building ❑ Distance to nearest lot line-- ----------------------------------------------------------- Remodeling and/or repairing (describe)_ -------------------- _ ------------------------------------------------ --------- -11 ,----- ,W -------- ------------------------------------------------------------------------------------------------------------- r= � I hereby certif that I have prepared this applicatioWand that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed)------------- 4-- e-------------------------- - - J-,Pwne.r and/or Contractor) B-----. •------------- :-•---:-------------------- - -- ---------------------(Title)----- -- ------------------- (Plot plan, showing size of lot, ,:location of syst m in relation to wel , buildings, etc., can be placed on reverse side). l' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -I ---------- DATE-- - REVIEWED BY- ------------------------ '------------------ ------- -- - ------ DATE --------------------- -------------- BUILDING PERMIT ISSUED .....--------------------- ------------- DA•TE.------------------------- -- - - ------------------------------------------------------------ - Alterations and/or recommendations_______________________________________. -------------------------------------------- - - ----------- ------ ------ ------------ ---- --------------------------- ------- --- =72 - --------------------------------------------------------------------------------------------------------------- ---- --------------------- 31 FINAL INSPECTION BY: -.__-._...- -- _A _ L` Date I� SAN JOAQUIN LOCAL HEALTH DISTRICT f30 South American Street 300 West Oak Stroot 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised V59 F.P.Co.