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w ,f� APPLICATION FOR SANITATION PERMIT Permit No. ../�1 _ ,� (Complete in Duplicatel This Permit Expires i 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 Ordinance No. 5 JOB ADDRESS AND LO TION----------- -------___ __ - wner's Name------------------ ------- ----- - -- -------------------- -- Phone----- Address-----•---•------------------ Contractor's ----------cContractor's Name1 .r1"Apartment -------------------------------- --------- --------------------------------------- Phone---)� /C ----------•---. - Installation will serve: Residence House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.1__- Number of bedrooms . Number Number of baths j----- Lot size __jQ-C-----)(-5V--_---___--------_- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table,4,1,0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lo Clay ❑ Ai obeHardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No FHA/VA: Yes ❑ No c❑� 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--------------------Material---------__-------.------------ _------___.---. No. of compartments------ -•-----------------Size------ -------------------.---Liquid depth--------------------------Capacity----------------------- Disposal --------------/----Disposal F' d: Distance from nearest well--------_-__.-.-.Distance from foundatio --- -- ---------Distance to nearest lot lin/- --------•-• Number of lines------------------I----------------Length of each line------- - -Q--._-_---------Width of trench.-_�--�!_�_----------------- Type of filter material-_:�r,2 c_i-------Depth of filter material---- - �.----_..Total length--- - - Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--.----.---- -- ❑ Number of pits----------------------Lining material--------.--------------Size: Diameter--------------.--- ----Depth--------------------------------- , 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 (descrike):- ----.----_ �,�_ ---------- - - cL --------- -------------------s ----------• ----------•---------•--------------------------------- ------------------------•-=---- =' --------------------- 7:----------------------------------------------------- ------------------------------- ordina ---------------------- --------------------------------------------------------------------------------:------------------------------------------------------------------------------------------------ - ------ I hereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin County Hees,.State lavis, and rules and ulations of the San Joaquin Lacal District. [FF (Si ned ,9 )�-----.----=-------------- --= -- - --- [z-.1�. .,----- --•Q.ss. s..�•---------- .- -- -s--R— ------- (Owner and/or Contractor) f--- - - -------------------- ' (Plo+,plan, showing size of lot,. I a+i n of sys'Fem in relation to wells,.buildings, etc., can be placed onkreve-oe,side. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY' .= f DATEI ------------------------------- -- I REVIEWED BY g R .v:� -- -�. ------------------------- DATE - - ----- ------------ BUILDING PERMIT ISSUED------------ =` - - a :.•'" DATE. -------- --------------- -r - —--------- Alterations and/or recommendations----------- ----`*.-_- ------ {---- - --------- -------------------- ----------------------------------- FINAL INSPECTIIO . ----- - - -- - ------ Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-92M Revised 8-'59 F.P.Co.