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APPLICATION FOR SANITATION PERMIT Permit No. -- - ��'1� L [Complete in Duplicate) 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 CATION____ ---- - ---- - --------------------- ------------------------------•---- ---------------------- Owner's Name - J -- ------ ---- ---------- - -- - Phon _ e ---lJ ` Address---------------------- :s !` — -------- -- -- E Phone Contractor's Name---------------- -- ---- ----j 1F.Y---- Installation will serve: Residence [Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other El Number of living units: ;QL__ Number of bedrooms ;?-- Number of baths -- Lot size ---- /4�__�l v---------------------------- Water Supply: Public system [�Commursity system El Private E] iii' Depth to Water Table -—ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [4;'�`New Construction: Yes ❑ No Ujo�rHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tanks or'cesspool permitted if public sewer is available within 200 feet.) pt nK' Distance from nearest well-----------------Distance from foundation____________________Material______-___.___.__.______-_______-----_________- ' '+7 Liquid depth No. of compartments - ----��---------�� --��Size--- -••----------------------- - G 1? ----- --------------• ODisposal eld: Distance from neare}t welllL�Fix—Distance from foundation__/d--f.---.--Distance to nearest lot line -1... Number of lines----/-_---- ----- Length of each line------------�?f&�-----.Width of trench------A7-�------------------ Type of filter material _ .-Depth of filter material------/_k-___.____Total longth__, __ _________________________f-_ Seepage Distance to nearest well__�2d'�"�-Distance m oundation___�lt.f______-Distance to nearest lot line----- Number ___/------------- l Size: Diameter---—3---- Depth c r�'r Number of pits_--_f ____.___..__Lining material____ ----------------- i Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- Lining material------------------------------------- "V ❑ Size: Diameter-------------------------;---------- -Depth-----------------` S { ----------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well----------------------------------_--------!_._Distance from nearest building.______________-_.._____________-----. ❑ Distance.to-nearest lot line"`----------------- -----------4% Remodeling and/or repairing (describe)--------------c~ ----------- ��--------------------------------------•--•-------------------------- --------------------`-'------------ ------------------ ----- . 7. -------------------- ---- --------------------------- ----- ----------------- ----------------------------------------------------------------------•------- I hereby certify,that I have prepared..fhisapplicafion and that the work will be done in accordance with San Joaquin County ordinances, to laws, n ,rules- Ore ulations of t e San Joaquin Local Health District. (Signed)----- 47111 ) --- -- ------------------------------------------------- ----------- Owner and/or Contractor) [rC� r gY� ' ----- -----------------------------------------(Title) 1 (Plot plan, showing size;of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ____: -------- ----- DATE f ' REVIEWED BY---------•--------------------------------- --------------- - --------------------------- ----------- DATE - - - - ----- ------ DATE--------- BUILDING PERMIT ISSUED----------------------------•--------- - - Alterations and/or recommendations-------- --------------- -� ---------...----------------------------------------------- -- 1 __ - - - - --_------------------------•------------------------ ----------------- , --------------- �: -�- -------------- .� �- •---------- ! - ! _ - ------ --------------- ------ ---------------------------------------------------------------- ------- --- ---::-.------- --------------------- ------------------------------ Date ----•--------------- FINAL INSPECTION BY: -------- Date.. SAN JOAQUIN LOCA ALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Reviseci 1.57 F.P.CO.