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FOR OFF.CE U E: r /,- , , --------`-_--_ ' �/+ f� Permit No.J.sa.. .`� APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Duplicate) Date issued _�_-:.t-.�--� � --------------- This Permit Expires'll Year From 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 N�,,, JOBADDRESS AND LO TI Nl _ """ -------------------••--------------------------------------------------------- Phone Owner's Name_------- ------------ Address ----------------------------------------- - -- -��- --..; ... ... R I �:. ,�._ `�,-r----- -- Phone---------_--------- /+ t Contractor's Name________________."��J -'---"-'"" Installation will serve: ;Residence 9E�—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms . _ Number of baths __/-__ Lot size ------------------- Water Supply:`Public system {Community system`❑ ..Private ❑ Depth to Water Table . D" t. Character of soil to a depth of 3 feet: Sand ❑ Graver❑ Sandy Loam El Clay Loam [I Clay ElAdobe[Hardpan ❑ Previous Application Made: (if yes,date----------- -} No { -"Naw Construction: Yes ❑ No R?"_FHA/VA: Yes ❑ No E- F € s TYPE- OF INSTALLATION AND SPECIFICATIONS: I `° •+•- ,(No septic tank or cesspool permitted if public sewer is available within 200 feet.), , Set,& T nk Distance from nearest well,''_i!_=__---Distance from foundation____..____k__ ._..Material__.>__"__________________________________________ 4>W�� No. of compartments.---" --- i._ Size----- ------Liquid depth_ '• Capacity Alp ..... to nearest lot line__ � ` � _""'__,Distance from foundation,___Alp •--------• Disposal Distance from nearest veli..._' length of each line_____ Width of trench. l� Number of lines---------------•--- Type of filter materiapth of filter l" _fy/ f� iDe •mater,ial;_ "�--Total length_______ :p.:-----•---•--- 1 \ Seepage Pit: Distance to nearest'well,____'=='__Distance fr Qm fou dation __ __.._..Distance,to nearest lot line...Y. Number`:of,pits-�___1_____;�_-,Lining material:= D Size- Diameter_ „_?_?�1------Depth_-__,9—_4P__!�------------- Cesspool: Distance from nearest well----------------'Distance from foundation____`____--_--__.fining material------------------------------------- ❑ Size: Diameter-----------r = Qepth - =---------------------------------Liquid Capacity-------•--------------------gals. 1 } r , Privy. Distance from nearest well----------------- _---_-_-______________________Distance from nearest building------------------------------------------ Distance to nearest lot line---- ' ---------•------=----------------------- ------------------ Remodeling and/or repairing (describe)a." ----_--14- - ----- E ----------• ---- ! hereby certify that I have prepared this application an d'that-the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District.. Contractor) (Signed)-------------------- -------------------------------------------- L Tltle ____________ By:.---------- ------------------- ---------------------(Title) 3 (Plot pian, showing size of lot, location off�systemxin _ tion to_wells,-buildings, etc., can be placed on reverse side). FOR DEPARTMEN USE ONLY APPLICATION .ACCEPTED BY------- .4eZ ------------ DATEr REVIEWEDBY -°--------------------------------- DATE---------- -•---------------------------------------------- BUILDING PERMIT ISSUED------:--------------------- - ------------------------ DATE---------------------------------'--------------------------- Alterations and/or recommendations:------------------ ---- -- .--------------------------------------•--------------------------•-------------- --------------- _ ----------------•---------•---------------------••-----•------•--------•--------------------------------------------------- :< �f ------------------------------------------------------------------------------ r" j FINAL INSPECTION BY:. - Date----------- --�-� ...... /----- ---------•------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streets "300.West Oak Street r`124 Sycamore Street 205 West 9th Street Lodi;;CcllFornla _\Mantsea Cal[fornla Tracy,California Stockton,California 3"_j „at , ti ES-9 REVISED 13-59 r.P.CD.SM 6-60 ` -