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' APPLICATION FOR SANITATION PERMIT Permit No. _K4 sI ___ (Complete in Duplicate) Date Issued � ?�_ 76_)_- pplication 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 aunty Ordinance No, 49. JOB ADDRESS AND LOCATIO -- ------- ----- AX Owners Name-__"��,-__.____ Address--- ----------------- Phone ------------••- Contractor's Name__--_-- _ - --- -- --- -- -- ------------------•---- --- -----------_-- Phone------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court (] Motel E] Other Number of living units: _.-- Number of bedrooms__ Number of baths ❑ ---- Lot size -------•---------- - Ater Supply: Public system ❑ Community system ❑ Private ❑ -Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes 0 No ❑ FHA/VA: Yes ] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet. �Se Tank: Distance from nearest w _- ' -- _ ------ Distance from foundation------------------.Materia)------�----- ---•-----.----•------_ No. of compartments--------------------------Size---------------- --- - ---------Liquid.depth--------------------------Capacity------ ------ _..--_-.. is Field: Distance from nearest well_ Distance from foundation-------------------- ` -_- Distance to nearest lot line------------ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------- ----- Type of filter material-------------------------Depth of fitter material-----------------------Total length________________________________ Seepage Pit: Distance to nearest wellLr.740---------- Distance from fou ation_._ P_' __Distance to nearest lot line- Number of pits-----_ ------ ---Lining material/ _- . - _ Size: Diameter-,! � ------..Depth-----Ao------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-- ❑ Size: Diameter--------------------------------------Depth------ - - ----------- Liquid Capacity---------------------- ----gals. ❑ Distance to nearest lot Privy: Distance from nearest well----- ------------ --- ---__-_--_-_pistance from nearest building line ------------------------------------------------------------------ A-111 Remodeling and/or repairing (describe)----- --------------- --- ----= ------ ----- - - ---- - - -- ----------------- --- - --•--- - ---... I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, a d rules and regulations of the San Joaquin cal Health District. (Signed) Contractor $Y:--------------------------------------------------- -(Titled---- (Plot plan, showing size of lot, location system 4 relation to wells, buildings, etc., can be placed on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ ------------------------ ----.- DATE---- --- --•-- t ------------------------------- REVIEWED BY----------------------------------- ---------------- ----------------------------- -------- ---------- ------------- ----------- ------------- DATE-------- _ BUILDING PERMIT ISSUED------ --- '- -------- -- ----- --------------------- DATE Alterations and/or recommendations:--____--. ._-- -- -----— ------------- --------------------------------------------------------------------- - 91 --- -------------- -- -- -- ---- ------- ------ j - -•--•- ------------------------------- FINAL INSPECTION BY: S Date 4- I — , 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M : Reviseo 1.57 F,P,CO,