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G APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate) / 1. ,. 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 c"mpliance with County Ordinance IN0. 5 9. JOB ADDRESS AND LO AIITION---------__-- ----- ---- - - -- - - -- - ----- --------------------•------------- NC � 1 Phone � ` - --------------------- Owner's Name------------ Address- /' Contractor's Name------------------- - -- />� _- G, G�� f ` � ---• ------ Phone. --------- --- Installation will serve: Resicltvnce [4--gp-artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units!!. i-__ ----- Number of bedrooms -!;;Zr Number of baths - Lot size.------ Water Water Supply: Public system [�ommunity system ❑ Private ❑ Depth to Water Table,//,91. Character of soil to a depth�I�f 3 feet: Sand Gravel Sand Loam Clay Loam Clay Adobe P �I ❑ ❑ Y ❑ Y ❑ Y ❑ 0--pardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well-----------------Distance from foundationiii -------�-----_----.Ma#erial-------------_.-_----.___ --------Size-------------------------------Liquid depth------------- Capacity------------------ No. of c'ompartments-----__-_-_.-_._ ___________ isposal ;Rd: Distance from.nearest well---------------- ta4ce_fr'om-foundation-.._s._._-------------Distance to nearest lot line----.-------_-_-. ❑ Number of lines------------------------ ------Length of each Iine----------------------- -----Width of trench Type of filter material------------ ----------Depth of filter material-----------lr----`-_--Total length------------------------------------------ Seeppage�t: Distance to nearest well- W, Distan m oundation_-_.- ...i-----Distance to nearest lot line------5_-------- sd of ts- _--Linin n=aterial-- _ ° e f Size: Diameter-_--- - Ali P ------- 9 --- - ------ t ��-Depth---..�-,. -------------------- Number Cesspool:_ Distance from nearest well---------------- Distance from foundation......__:_----t----.Lining material._-_.--______-_--..--------___-----. Size: Diameter---_-. pe Depth:�..��.. .. � �� p -- Liquid Capacity,... gals. ....� �= .�tee:.,,.. .. �.ia_01 .. - . "" Privy: Distance from nearest well-------- .-.-Distance from nearest building Distance to nearest lot line----------------I- ------------- ----------------------------------- Remodeiing and/or repairing(describe):--------------------------- = =— ------------ ------------- =— ---------------------- •------------------ ------------------------------------------------- ' ----------------------------•------------------------------•-- I hereby ce that I ha prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S to law and rules and regulations of the San Joaquin Local Health District, (Signed)------------ ------- --- I' Y r and/or Contractor] - ---- ------------- itle) W-e or (.Plot plan, showing size of lot,�location of system in relation to well ildmgs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY ------------------------------------------•-------------------- DATE.------ -----•---- REVIEWED BY------------------------I ----------=----------- - - M ; C` ------------ -------------- DATE---------rte ` - ------ -------------- BUILDING PERMIT ISSUED-----F----------------------------------------------------------------------------------------------- DATE. ---------------------------------- Alterations and/or recommendations: 1111 ---------------------------•-------- ----------------------•-------- ----------------------------------------------------------------•----------------------------- -------------------•-------------- ----------- -•------------------------------------- ---------------------------------------------------------- ----- -------------------------------- -------------------------------------------- -------------------------- ---------------------------- ---------•-----•------------------------------------ I --------------------------------------------- --------------------- i f f� FINAL INSPECTION BY:. r - ------- Date ------ - - --- -----r ---------✓ 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-4-21A , Revises 5.57 F.PCO, t i J 1.