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APPLICATION FOR SANITATION PERMIT Permit No. -_L/-3`� (Complete in Duplicate) Date Issued _Cl----F� /Iss Application is hereby made to the San Joaquin Local,Health District for a permit to construct and install+he work herein described. This application is made in compliance with County Ord' nce - 5 - TION. ------ JOB ADDRESS f�ll� L /� • � 4 - Phone------------------------------------ 5 --------------- ----------------- Owner's Name - - '� ________6____________________________________________________________________________�_- Address-------------------�� -------------------- Contractor's Name___ __ ----- Installation will serve: Residence ®, partment House F1 Commercial ❑ Trailer Court ElMotel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms _ - Number of baths ---I--- Lot size ------•---------------------------- Water Supply: Public system R Community system F1Private ❑ Depth to Water Table __yQ_ ft- Character of soil to a depth of 3 feet: Sand ❑• Gravel El Sandy Loam El Clay Loam ❑' Clay ❑ Adobe [ Hardpan ❑ Previous Application Made- Yes Q No ❑ New Construction: Yes [4 No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well_: _----Distance from foundation-_/fir---- Material_--- `� ® No. of compar+ments_____._ - --.---- - Size -XcS` Liquid depth----- / Capacity.:i Ud � Disposal Field: Distance from nearest well�!1v?�---.-Distance from foundation_/�-�---^-_-_._ +l,d#hcofttre ch e5yt-line-_�3'�-_.-_-- l Number of lines-----2------------------ --- ---Length of each line-- - -- Type of filter material___-: pc _--_----Depth of filter material__!$`---- -------Total length___``!2---------------------------- ---- / i ( -_______..Distarce to nearest lot�ine_'S__-___--.._ p . _,_34'r � Distance to nearest well '`t Distance from f undatian_ !" ' _Size: Diameter -k-7--.--------De-pth.-`y--------------------------- ® Number of pits--------�------------Lining material____-----,- ---- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------------als- ❑ Size: Diameter---- ---=----- --- ---- -------- Depth-------- -------------------------------------------Liquid Capacity----------------------------g - Privy: Distance from nearest wO--------------------------------------------------Distance ----------------- ------------------------------Distance from nearest building-------.-------------------------------- ❑ Distance to nearest lot line----- -- --------------------------------------- Remodeling and/or repairing (describe):----- _ _ -_ .- ------- -- -------- --------- --------- - ------------------------• ----------------------------------- ----- --------------------- ----------------------- -------------------- --------------- j I hereby certify that I have prepared Ibis.application and that the work will be done in accordance with an Joaquin County ordinances, State laws, d rules and regulatio of the San Joaquin Local Health District. ------------------------(Owner and/or nd/or Contractor) (Signed) -- ------- By---_-------------- ---------- 4`� ---------------------------------- ---------------(Title) C- GIS- ' '� (Plot plan, showing sire of to+, locati n of system In relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY DATE-----------------------------------------;.--5- -------- APPLICATION ACCEPTED BY---------------------------- DATE---------------------- ------- ,.� ---- ------------------------- ------------------------------------- REVIEWED BY---------------- -------•-------------- ------_ --- ---------------- DATE----------------------- BUILDING PERMIT ISSUED--------------- - -0-- -------------- -------------------------- - Alterations and/or recommendations: - = -------------------------------------- ---------------------------------------------------------------------------------------------- ---- ---------------------------------------------------� ' VFINAL INSPECTION BY:------- - - 1 - ----- Date---- - ----------------------------- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT Y 132 Sycamore Street 814 North "C" Street \ 130 South American Street 300 West Oak Street Y Trae California Stockton, California Lodi, California Manteca, California —2M , Revises 1.57 F_P-Co: