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V APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health Di If r a permit to construct an stall the work herein described. This application is made in compliance with County Ordinance 11��,9 construct a stall the work 101 ADDRESS AND&CATION.------------ - - - -- - --------- ----- ------------------------------- Owner's Name------ -- ---- ---- ------------------------ - ------------------------------- -------- Phone------------------------------------ --- --------------- - ---- Address-------------------- - ------ ------------ Ph Contractor's Name - 0 r M U?-,;(Partmen ouse E] ommercia[ E] Trailer Court E] Motel 0 Other E] Installation will serve: Resi ce Number of living units. -3--"'Number of bedrooms --- umber of baths __:?�Lot size ----—--- mmunify system 0 Private E] Depth to Wafer T Water Supply: Public system EJ�Cl it. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Ej Cla am E] Clay [] Adobe D—_H_"ar4PQn []�L -1 No 2--�Ne, Construction: Yes E] No Previous Application Made. Yes E_ FHA/VA: Yes E] No E] TYPI,OrTNSTALLATION AND SPECIFICATIONS: o septic tank or cesspool permitted if public sewer is available within 200 feet.) repf Distance from nearest well-----------------Distance from foundation--------------------Material----------------------------------- ------------- No. of compartments-----------------------.__Size--------------------------------Liquid depth--------------------------4Capacity----------------------- 1,F gi : Distance from nearest well-----------------Distance from found&ion-------------- -----Distance to nearest lot line__-_-__-----_--_. Number ine----------------- Number of lines-----------------------------------Length of each line----------------------------.Width of french----------------------------------- Type of filter material----- --------------Depth material--------- Total Ile gth-------------------------------------/ ",fp or --------- -D Di n nearest loijine Seepage Distance to nearest we,, ---Distan foundation---1-0, --------- EP>P Number of pits--__x----------------Lining maferiallia",___---.-_.Size: Diameter__. .. Depth_--<:2.111------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_-_-_---_.__.---_______-.--_-__-_-. ❑ aterial-------------------------------------- El Size: Diameter--------------------------------------Depth- ------------ -------------- ----------------------Liquid Capacity----------------•-----------gals. �' Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building-_--_---._._--_-_--_--_-_______.___._____- ( , ❑ Distance uilding------------------------------------------ Distance to nearest lot line- ----- ----------------------------- --------- Remodeling and/of repairing (describe)----------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------1-1---------------------------------------------------------------------------- --------------------------------- ------------------------------------ - --------------------------------------------------------------------------------------------------------------------------------1------------------------------------ I hereby certify t--------have prepared this-application and f:h f the wQrk-.w4fl be done in accordance with San Joaquin County ordinances, State and rules/. d regul ti ns of th n ;in ealth District. /7o - - --------- -------- (Signed)------4_��O ---I----V61-------------- - -- -------- ----- -------- -------- Contract or) By:-- -------------------------------------- - ------ ----- -------I-- -- ------- ---------------{Title _0 -------- -------------------- (Plot plan, showin size of lot, location of to. in lotion to wells, 6uiletc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- BY-- ----------------------- ------------------------------------------------------------------- DATE REVIEWEDBY---------------------------------- ---- - ---------------------------------------------- -------------------------------- DATE-I--L .t�—-------- BUILDING PERMIT ISSUED--------V--------------------------------------------------------- - ------ DATE-----. - ----------------------------------------------- Alterations and/or-s"cio"m;Menda-tions: - ( ------------A------------1-1--1--_-- ------------------------ ----------r----- --- --- --------------------------------_-------------------------------------------------------------------------------------------------------I---------------I------------------------------------------- - ---------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------I------------------ ------------------------------------------------------------------------------------------------------------I----------------------------------------------------------------------------- -------------------------- - -------------------------------------I------------ ------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:------ -- - �--------------- --------------------- Date----- ---------------------------------------- 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 E5-9-2M - Revised 1-57 F.P,CO.