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= �1� APPLICATION FOR SANITATION PERMIT Permit No. .L - .____ (Complete in Duplicate) f 1 C 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. 5144. .! . JOB ADDRESS AND LOCATION_ -- -�'- -- -- ¢- Owner's Name-------------- ------ ----------------------------------- - --------------------------------------- -- Phone------------------------------------ Address------------------------- .�.. Contractor's Name --------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence P__Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other ❑ Number of living units: _/--- Number of bedrooms _X__ Number of baths __/__ Lot size _ �[,�__-------------------__________________ Water Supply: Public system`❑ Community system ❑ Private Rj--5epth to Water Table _Y 'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No [' New Construction: Yes ❑ No [ FHA/VA: Yes ❑ No H�-' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Tank: Distance from nearest well________________Distance from foundation--------------------Material ___________.--_- No. of compartments--------------------------Size-----•-------------------------Liquid depth---------------- ---------Capacity......----------------- isp sal Field Distance from nearest well-- _ ----Distance from foundation--- %d ---.-.Distance to nearest lot line�_�`_____.___. - tNumber of lines_____________ Length of each line----_--�� -_- Widfl offrench----!��Ed_----______________ ------ ......... Type of filter material f _. __Depth of filter material___..�fTotal length_______.�oif __ ________________-- ` - �� / Seepage Pit: Distance to nearest weli___� _----_---Distance from f ndation---�i��_____.Distance to nearest lot line__,eZ.-________ Number of'pits-----.�------------Lining material=__�/ Size: Diameter__..?Y_-.___.__--Depth____A-0----------------- ------ 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 - -------------------------------------------- �� Yh Remodeling and/or repairing (describe]:__t----------- i� --------------------------------------------------------------------- V --------------•---•------------------••---------------------- a ------------------------------------------------------------------- ------------------------------------- ----------------------------- I hereby certify that I have prepared this application and 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. r (Signed) r -------- - -- -- - -- -- - --------------------------- - --------------( ar Contractor) 'fie) f es°?.4 -�'By:------------------A-----------------t'-•--- � (Tr _ (Plot plan, showing size of lot, location esystern in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ --t •.9—AQ---`---------------- - ----- DATE---------5_ -- - --- --- ----------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE------------------------ BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations---------------- ------ ---------------I----------------------------•------------------------------ '' Tr ------------ . 5' ---p-,-�-------------- ----------------------------------------------------- -----------------4_F5X:T�-l--------0- ._. 'I .............W- `---------------------------------- ----------------- ---------------------CaN_N,Z,�_'T.-- _S-- --------- -r_�_.------•--------------- ------------------------------------------------------------------------------------------•------------------------ ---- ----- - -- - -------------•- ---------------------------------------------------------------------------------------------- FINAL INSPECTIO'1—&Y-; _ Date------------- __57-- ----------------------------------------- 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-4-21x1 , Revises 1.57 F.P.CO.