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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _OApplication is hereby made to the San Joaquin Local Health-District for a permit to construct and install the'CoMe'rein describe�2 This application is made in compliance with County OrdinarLce No. 54 JOB ADDRESS A J�OCATIONI `r{------_ - M_1�0— ----- ----------- -------------------- - ---------------------- -------4�_� ----- Owner's Name____��_ ------------------- Address----------- --------------f 7 F - ----- -- --------------------------------------- Contractor's Name------------------------ ---- Pn�_�/ i----_�--- _ Installation will serve: Residence E] Apartment House E] 1, Commercial D Trailer Court 0 Motel 0 Other 0 Number of living units: __/_ umber of bedrooms_ Number of baths _/__ Lot size __._ 4 --—------------- /// Water Supply: Public system E] Comm6nify system [] Private R?'15epth to Water Table' ft. I 1� Character of soil to a depth of 3 feet: Sand E] Gravel 0 Sandy Loam E] Clay Loam Rl`oc'lay E] Adobe 0 Hardpan E] Previous Application Made: Yes 0 No jr"INew Construction: Yes 0 No g9-'_F'HA/VA: Yes E] No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permiff'ed if public sewer is available within 200 feet.) e is Distance from nearest well-----------------Distance from foundation---- --------------Material--------------- --------------------------------- No. of compartments_l------------ ----- .--`Size------------------- ---Liquid /depth--------------------------Ca'p acity----------------------- isposal Fi Distance from nearest well/ow--- Di,stance from founclafion_�_�__ ----Distance to nearest lot Number of lines Width of french__,7!?_.,�'-. lines_-_._ ..._.___.... -- Length of each line_,120--_�-----i-i------ Type of filter material-- _4Depth of filter material---- =_____..__Total length---------------------;?O��----------------- -6 ( — # -ince to nearest ------ 17,` ------Distance to nearest lot Seepage Pit: Distance f Disfan9d _r, I fopindation-_'. Number of pits-- ------- -------Lining material-- Size: Diameter--3-3----------- 171 Depth- ---------------- Cesspool: Distance from nearest well-----------------Distance from foundation----------I---------Lining material_--__---._..--------.--------_-_-_---. ❑ aterial-------------------------------------- F1 Size: Diameter---------------------------------------Depth--------------------------------------!---t--------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------11-771------- ---------Distance from nearest building-___-_---------.-__----___-_------.--_-_. ❑ 0cling----------------------------------------- El Distance to nearest lot line---------------------------------- --------------------------- ---------------------------------------------------------------------- Remodeling and/or repairing (clescribei):-------------------------------------------------------------------------- ----------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- -------------------- -----------------------------------------------------•-------------------------------------- ------------------------------------------------------------------------ I hereby ce if t at I have prepared this a licaflon and that the work will be done in accordance with San Joaquin County ordinances, Sta44 la and rules an egulafio s f the San Joaquin Local Health District. (Signed)---------- - --------------- - M (9wner and/or Contractor)- ---------------------------------- By:---------------------------------- - ----- ------------------------(Title)----- G_ �4---] ----------------------------------------- (Plot plan, showing size of lot, 10 tion of system in.relation wells, buildings, etc., can be placed on reverse side). FOR DEPATMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------ -- ------------------------•--------------- DATE-'T-- --------------------------------------------------- REVIEWEDBY------------- -------------------------------------------------------------------------------- DATE__34_0----------------------------------------------------- BUILDING PERMIT ISSUED ----- -_---------- - ------------------------- --- -------- ---------------------------------------------—-------------------------------------- DATE---- V\ ------------------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------------------- ------------------------------------------------- ---------------------------------------------------------------'=-------------------------------------------------------- -------•-- ------------------------------------------------:1----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- -----•---------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- -------------------------------- -------------------------------------------------- ----- ------------------------------- ------------------------------------------------------ ----------------------------------------------------------------------------- FINAL INSPECTION BY� ------------------------ ----- ---------------------------------------------- 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-9-2M Revised 1-57 F.P.0O3