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1 t-s 1'-- 7 . � APPLICATION FOR SANITATION PERMIT ✓ Permit No. ------.fV__• k91111 (Complete in Duplicate) 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 . 5 9. JOB ADDRESS AND LO fON__.- -- --•-- --- �__-- ..__ �y "= f�rXi� Owner's � �! e s Name-------- - ----• --- ---------------------------- ---------------- Phone-----•------------------------------ Address �---- r Contractor's Name �ar ---------------------------------------•-•------------------ Phone----------------------------------- . will serve: Residence [Apartment House E] Commercial [-] Trailer Court E] Metal El Other El Number of living units: j--- Number of bedrooms -..;1_ Number of baths _#Z_ Lot size Wafer Supply: Public system ❑ Community systemPrivate ❑ Depth to Water Table ___��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan El Previous Application Made: Yes ❑ No [� New Construction: Yes g]^No ❑ FHA/VA: Yes [5----Mo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s r.is available within 200 feet.) Septic Tank: Distance from nearest we .. .-_____Distance fm foundation----le---------Mater al----�,r . _. No. of compartments_-__. gg ........ _ Size__p yox-4 _ _ ..._.Liquid depth ___ --_-------Capacity-____ - -- ------ v'-� Disposal Field: Distance from nearest ell_ Distance from foundatio __ "' pp �' � -- Distance to nearest lot Iine_._.Q_________. Number of lines__________ ____ ength of each line______ ------, -- _' r� Width of trench.___- �r �} -------------- Type of filter material._.____�� _.. _ epth of filter material______�D__ _____Total length------ ------------_______ Seepage Pit: Distance to nearest well.-'Distance from fo dation__- __.-..Dist 4e to nearest lot line Q.._ p �---_------Linin material-_- --- s—U ��- [�}� Number of its_-..__ _ g -----Size: Diameter.__ _..r- p ....... „- � Cesspool: Distance from nearest well----4----`-----Distance°from foundation----------------------Lining material_--.__-______-.__-___.--_..__-__--__ ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----------------------------------------- Distance ---____-___-__.-__.___-_.._.Distance to nearest lot line--- ----------------------------------------------------------------- Remodeling and/or repairing {descriEae�= f / -- -•- -- -- ----------------------------------•------------------------- ------------------------------------------------------•------•------------------- --------------------------------------------------------------------------------------------------------•------------------------ --------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rule and ;;Ia�fionsf, he San Joaquin Local Health District. (Signed)----------------- ` --- --- ---------------- ------ Contractor) By:. ----'---------�----- (Title) 1'-------------------- (Plot plan, showing size of lot, locatio sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ ------------------------------------ -------'” DATES REVIEWEDBY------------------------------ r (� - ---------------------=---------•----------------------- DATE__Z-------------------- -------------------------------- BUILDING PERMIT ISSUED------------- - --------------------------------------- ------------------------------------- DATE------ ---T, Aiteratior}s and or reco endations:__.____.._._._____..__�,,,___.-________ ----- ----------------••-------------------------------- t -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------ ------ ------------------------------------------------------ ---------------------------- -------------------------------------------------------------- FINAL INSPECTION BY____ _ _ _ Date. - - ----------------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P,CO.