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APPLICATION FOR SANITATION PERMIT Permit No. ___j___K7S (Complete in Duplicate) a �� $701✓� '.;, 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 compliant wi h County Ordinance No. 5 9. JOB ADDRESS AND CATI - -- ----- ----- - - -- ---- -------- --- - - ------------------------- Owner's Name----------- -------------------------- ------- Phone ------------- -----_------------ Address ............. X/�--- Contractor's Name ------------- - --• -------------•------• ----------------------------•------------------------ Phone -------------------------•--------- Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel []''Other ❑ f Number of living units: _ f ___ Number of bedrooms :5.?_ Number of baths /j : Lot size _ � ��______________________________ Water Supply: Public system ❑ Community system Private ❑ Depth.to Water Table 7,j --ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 9?'*'C-lay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ `No *,,-New Construction: Yes VTO"No ❑ FHA/VA: Yes Rw�'-No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.orticesspool permitted if public sewer is available within 200 feet.) f Septic Ta sfin from nearest well _��______ Distance from foundation ----/I--- __-.Materiai__ I- _ �.y ---- u.. No o compartments______.__________Size*�_dl1_){��e±Y_0iquid depth____: ------- :_-.7 Ca pacify_.,/ Disposaa field: Distance from nearest w ll__&E__._____ Distance from foundati n__XP____.Distance -to nearest 1 t line__________ _ [s Number of lines ---------- __ ._____ Length of each line______ �_ _� Width of trench -----f'________________ i r Type of filter material__ epth of filter material_____ __f�____Total length ______,/�*-_----___________________ Seepage it: Distance to nearest well ----- l,�,l/__Distance fr foun d ation___ _�______ Distance to nearest # __.._ U Number of its______._ Size: Diameter-_ .r� __ __ a p-�--------,Lining material---- --- � +�,� --- ---- Depfh--4kP -------------------- Cesspool; Distance from nearest well ----------------- Distance from foundation -------------------- Lining material ------------------------------------- El _-_..._______________________--___-❑ Size: Diameter -------------------------------------- Depth ---------------------------------------------------. Liquid Capacity- . ------------------------- gals Privy: Distance fromynearesf well-_________:_-___---------- _--------------------- Distance from nearest building ----------------------------------------- 11 Distance to nearest lot line----------------------------------------------a------- ---------------- ------------------------------------------------------------ Remodeling and/or repairing (describe):- ------ ---- -- -- - ------------•-------------------------------------•------------------ ------------ ----------------------------------------------- --------------------------------------------------------------------------------------- - -----------------------------------------------------------•-----------------------------------•------------------------------------------------_------------•----------------------------•--•------------------------------ - -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StatWlaws,and s and regulations of the San Joaquin Local Health District. (Signed)S--' -- ------------- -------------- ----------------------------(�r Contractor) BY: ----•-----• ---- --- _- = _ x`--------------------------------- (Title} - %%z `'..' ................----- (Plot plan, showing size of lot, locat' of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- T 7R, v-------------------------------------------•----------------------- DATE------- -(� ----------------------- REVIEWEDBY------------------------------------ ---------------- DATE ---------------- BUILDING PERMIT ISSUED -------------------------------------------------------------- ------------------------------- --------- DATE ------------------------------------------------------------- Alterations and/or recommendations----------- ----------------------- ---------- --------------------•-------------------------------------------------- •-------------------------- ---.. ---------------------------- •---------------------------------------------------------------------------------------------------------------------------------------- ----------•------------------------------------ ---------------------------------------------------- -- ---- ------------------- ------ -- -------- -------------------------------- -•------------------••------------------------------------------------- -------------------------------------- ------- --------------- FINAL INSPECTION --- -- ------ - ----- -- ----- --- ------ ---- - -- Date--. U SAN JOAQUIN LOCAL HEALTH DISTRICT. 130 South American Street V 300 West Oak Streets } 132' Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised 8-'59 F.F.CD.