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FOR OFFICE USE. J APPLICATION FOR SANITATION PERMIT Permit No. --------------------------------------------------------- ------------------- ----- ------------------------------- (Complete in Duplicate) Date Issued --- --------------------------------- -----------------------------_____.__-.__.___.__ This Permit Expires 1 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 o. 5 9. JOB ADDRESS✓AND. LOCATION________-• � C - 4oe F --- ------ Owner's Name_ � +. F - ---•--•-------•--•-••--------_-----------•-•----- Contractor's Name---__ - . r---------- •------------ Phone. -------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑01. Motel ❑ Other ❑ Number of living units: .___ Number of bedrooms._ Number of baths - Lot size . _ �pp .--'---••- ---------------•--------- Water Supply: Public system ❑ Community system �Trivate ❑ Depth to Water Table ._ tt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R--nardpan ❑ Previous Application Made: {If yes,date-----------_--------) No Raoo'* New Construction: Yes Vae*No ❑ FHA/VA: Yes 9;- No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if'public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel____"__�_�____Distance from foundation____/0___.____.Material__ .��_____________ - -' ---Liquid depth__...------------. Capacity. /2+l�iP`_. No. of compartments_.,_ ___________________Siz Disposal Field: Distance from nearer well------ -Distance from foundation.../f+'-----------Distance to nearest lot line_�r-....- W'` [� Number of lines______ _____�___ _,,Length of each line_____ ____�� Width oftrench_----A ___-------------------- (P Type of filter material /�� Depth of filter material.__ s - length-'-- .. ---------------_---------- Q Seepage Pit: Distance to nearest well-------- -----_____Distance fpm foundation----ZP__-..___.Dista`ce to nearest lot line__° .--------- Number of pits------. ---_____Lining material-__,�i_ _ee4 C._Size: Diameter__ _____...__Depth_.v ✓_______________ �Z Cesspool: Distance from nearest well----------------- from foundation.- -----------------Lining material__.____________-______________---___. ❑ Size: Diameter-------------------------------------Depth---------------•-------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------_----------------------------------Distance from nearest building------..______________-_-__________-___._. ❑ _. Distance to nearest-Ibt-line------- -�---------------- - ---------•-•----------•------------------------ -•-------------------------------------•----•------------ --- Remodeling and/or repairing (describe):------------- ---------------------------------------•------------------------------- -----------------------------------------f------------•--•------------------------------------------ --------- 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, a d rules and regulations of the San Joaquin Local Health District. - -(10WISr Contractor) (Signed) -- ---- ----- IA :" ---------------------------------(Title)--- � "--------- ---- -------------- (Plot plan, showing size of lot, location stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARJMNT.USE ONLY APPLICATION ACCEPTED BY----.- - ----- -------------------- DATE.._./f--��------- ------------------- REVIEWED BY --------- DATE y BUILDINGPERMIT ISSUED------------------------------------------------------ -----•-—-------------------------•------------ DATE------------------------------------------------------------- Alterations and/or recommendations--------------- -------------•-------------------------------------------------------•-----------•-----•----...--------•-----------•-•--•--------•------------- ----- -- --- -- - --- - - - ----------- ---------------------------------------------------------- ---------------------- ----- ------------------- -------------------------------------------------------------------------------- ------------ ------------------------------------------------------------------------• FINAL INSPECTION BY ..:. ------ ----- ------- Date------------ ----'-- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street k. 4 124 Sycamore Street �y 5 205 West 9th Street Stockton,California Lodi,California ' " Manteca,California , , Tracy,California E6-9 REVIeEo B-59 F.P,GO.2M 6.60