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APPLICATION FOR'SANITATION PERMIT Permit No. _.-!_. `. o (Complete in Duplicate) Date Issued3- -.--- This Permit Expires I Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit�o construct and install the work herein described. This application is made in compliance with County Ordi nce No. 5 �I(1 R1x JOB ADDRESS AND CAT N--•. - -�. - - • ---- - -- - --- I -------- - --------- -- -- - - Owner's Name------- ----=---- ------ Phone_ a Address------------ ------- �/ -- - ----- - - Contractor's Name_ ----- ----- Phone__ Installation will serve: Residence' artment House [I Commercial ElTrailer Court [I Motel then ❑ Number of living units: /__- Number of bedrooms -_/__ Number of baths __/__ Lot size ,� ---------- ----------- Water Supply: Publics stem Comn it system ❑ Private Depth to Water Table��ft. PP Y: y ❑ Y Y ��_. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,4' Hardpan ❑ 1. Previous Application Made: YesX No ❑ New Construction: Yes)< No ❑ FHA/VA: Yes ❑ NoX _j TYPE OF INSTALLATION AND SPECIFICATIONS: k (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation_-_----_-__---....Materia l-___--._____---_-_---.__.___-_-__----.---._-_-_. Q. No. of compartments--------------------------Size -------Liquid depth Capacity ' istance to nearest lo�line. ___._ posal eld: Distance from nearest well___ .-_-_..Distance from foundation _...- - Number of lines---------- _ _ Length of each line_____sl_ _--____.:.Width of trench_. ___._______ ____-______ i __ otal len th -2 Type of filter material,.- --Depth of filter material._ _____--__ 9 Seepage Pit: Distance to nearest well_ G��--f----Distance from f datio ista'ce to nearest lot linen_____..._ j Number of pits------/--------------Lining material A------Size: Di eter---, 3------------Depth---- Cesspool: Distance from nearest weil-----------------Distance from foundation-------------------.Lining material--------.--------------.- ___ls._.. - ❑ Size: Diameter---------------- -------- Depth----------------------------------------------------Liquid Capacity---------------------- gaj, Privy: Distance from nearest well-------------------------------------------- Distance from nearest building-------- -- ----------------------- ❑ Distance to nearest lot line-------------- - ----r------ ---------- ----------------- -- ------- -•------ ------- ------------------- - r /07 l r f mode Ii •/or repairing (de .cribe):__� =u- � E •-- �: = r = ------- _ ------------ - ., -- I hereby certify that I ave prepare tis ap lica#i n d that t work will be don m accordance with San Joaquin County ordinances, State laws -nd rul an re ulation the Joaqu' L�acal Healt istplct. (Signed). • ................ --------------- ---------- - _(Owns d/or Contractor) $Y� - --- --- ., --._ (Title)- ---------- ------------- I (Plot plan, sh fl cation of system in relation to wells, buildings, etc., can be aced on rever side). E T FOR DEPARTMENT USE ONLY - DATE---l`--•-- --- ----------------------------------- APPLICATION ACCEPTED BY_ REVIEWED BY---------------------------------------------•--------------------- -------------------------------------- DATE---------------------•------------------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE--------------------------- --------------------------------• } Alterations and/or recommendations------------------------------------------------------- •-=----------------•------------------------------------------------------=-- --------------------------- --- ---------- ---------------- ----------- ----- 6� J / r ` FT `►rte` - -- ------ -- - , Date__.----- -, FINAL INSPECTION BY:.------ --- : N JOAQJ14POCAL HEALTH DISTRICT !1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21M Revised 6-'59 F.F,Co.