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APPLICATION FOR SANITATION PERMIT Permit No. __ - .�__ ~ (Complete in Duplicate) �. _ —~ ss . _ ...». . 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 Ordinance No 5 JOB ADDRESS AN LOCATION i �- 4-r r ••-------- Owner's Name________ _ ___ _ __ ----- ----- --- -------------- -=---------------------------------------------------- Phone--------------------------------•- Address " _---------� ------------------------------------ --- ----------. Contractor's 'Name------------ =.s . . "------------------------------------------- --------------------------------------------------- Phone----- ----------------•---------_ Installation will serve: Residence R"Apartment Nouse ❑ Commercial,❑ Trailer Court ❑ Motel ❑ Other ❑ `. i - �4 �2,0 Number of living units: /_--__ Number of bedrooms _ Nusi�laer of baths __._ Lot size ____________'________________________________._____.._ Water Supply: Public system Community system-[IPrivate F1"Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑,,, Clay Loam ❑ Clay ❑ Adobe F1'o`Hardpan ❑ Previous Application Made- Yes ❑ No New Construction: Yes �o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or`cesspool permi+ted if public sewer is available within 200 feet.) Septic Ta e Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- El _____.-- --__-----_---__---_---__----.---_ -.❑ No: of compartments------------------------Size----------------------------:---Liquid depth------------ -------------Capacity Disposal R Distance from nearest well-�_(_�/P_.__Distance from foundation-/,__f�_ .i.Distance to nea"rest lot�l�n ---------- 's Number of lines_._-__- ----.- tree Length of each line___ ( _ ___S� Width of trent '___ ___ _________________ Type of filter materia4 7________.-__ epth of filter material-__----� -----Total length----__- .— page Piva�QJ'"'j Distance to nearest well_____`._"____________Distance from foundation---------------------.Distance to nearest lot line______.--._._____ ❑ ¢� Number of pits---------------- -----Lining material---------------------.Size: Diameter------------g--------.Depth--------------------------------- esspool: Distance from nearest well-----------------Distance from foundation._."._._-.-:____..Linin material------------------------..-_--_---.-. - Size: Diameter----------------i----------'-''- -------Dep+h---..------------------- - --------------------Liquid Capacity------------------------- -gals. Privy: Distance from neeresT well--------------------------------------------------Distance from nearest building------------_----------------------------. ❑ Distance to nearest lot line_ *mar=_ -------------- " -- -- --------•- .---------------------------------------•-------- ------------ . Remodeling and/or repairing (describe)--------------q ---------------`•; `. ---------------------------------------------•------------- ---------------------------------- IF x l T 4 ___.______._____ --------------------------------------------------------------------------------------------------------------------------------------------------------------.._-_-__.--_.-_______________--------_-_-----___. -�a y - ----------------------------«.-.___._---__.--________--____-------:---_---__ _—.____.--_---__---__------__---_.--____._---____- ______----______--_-___-------------------_------------.-_____._____________._..___ .... a _ _ _ I'l _ _ __ _ _ _ ! hereby certify that I have prepared this applica+ion-And_th.at the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulation-s of the SanaJoaq n Local Health District. iV(S � i -- - (Owner and/or Contrac+or)i ned --- _O m ------- -= ------- -------- B . (Title) — " (Title)___..-__-__-__-____----._ ---------------- (Plot plan, showing-size of lot, lova+ion of'system in relation to wells, buildings, etc., can be placed on reverse side). '_ , •", FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- -------------------- DATE------------------------------- � --------------- REVIEWED BY - ------------ --- - -- DATE BUILDING PERMIT ISSUED_::.- n__- - • -- --------------------------------------------------------- DATE----- Alterations and/or recommendations:------ --` - --- ---- ------------- ---------------------------------------••-----------•--------c G e -- ---------•---- -•-- --------- -----------------------• ---------•-------------- -_------------------------------------•----------- ----------------------------------------------------------- ------------------------ - -=---•-=--- j% 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. l