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� APPLICATION FOR SANITATION PERMIT Permit No. /K k� (Complete in,Duplicate) Date Issued s til. Application is hereby made to the San Joaquin Local Health District f9 a permit to construct and install the work herein described. pP This application is made in compliance with County Ordinance N� V ----------- ----- ^ I /. ------JOB AQDRESS AND C 1 ----------------------::�- -- ------ ----- - -_- --- .Z 3 Ph Owner's Name--- - ----- -- -- ------ - a ` - .. Address------- Phone Contractors Name___________________ ___ __ �- ------- `• .ac#ment-House, - _Commercials •Traile_.- urt ❑ Motel ❑ Other 0'/ Installation will serve: Residence ❑ Ap ❑ II ------ Number of living units_ _____-,Number Number of bedrooms -_------ Number of baths -_-._-- Lot size ----__ -----•----------- I Depth to Water Table -{�_S__ ff. Water Supply:'. Public system �$ Commuriity system ❑ Private ❑ P Adobe ardpan ❑ Gravel Sandy Loam ❑ Clay Loam'❑ Clay ❑ Character of soil to a depth of 3 feet: Sand ❑ ❑ No ❑ No New Construction. Yes ❑ Na �1{A/VA: Yes ❑ Previous Application Made: Yes ❑ � � ,.� TYPE OF INSTALLATION AND SPECIFICATIONS: L. No septic tank or cesspool perm' "p l able within 200 feet.] ( p Distance from nearest well_____________ _Distance from foundation---:--------•- Material-----.--------------------- rtted if"public sewer is available S fi ank: ea Capacity No. of compartments- Size----------;= -- -------_Liquid depth-------------------------- p Y 4f I '' spo i Id: Distance from near t well_---.-- _Distance from foundation--- --.--.Distance to nearest lot-line=----_---------- 11 Number of-Jines-ZA---------------------------Length. of each line----------- Width of trench. ----Total length-----------------------------------•------ r ' Type of filter mat eral--_-- D5 pan of doter material ation___. d_ ___.Distance to nearest I line--- -�-- l. - p g well-_fes✓--- See a e Pit: �lumabereof p'}S rest',--.--- --Lining material� .5¢e: Diameteyr-- - ----�------Qepth---------5------ tante from.lneares# well----------------- from_foundation---------------`_---.Lining material-_-_-----_-------_----._-----_--_--. Cesspool. Drs --__� .-Li uid Capacity -----------gals. ❑ Siie: Diameter------'. ---------------„-----------Depth------------------------------ st well Distance from nearest building--------------------------------------------- ------------------------------------ - Priv ------------- -------------------- Privy.. Distance from Weare ---___-----_---------- --_ I ❑ Distance to nearest lot line_------------s------------------------------ Remodeling and/or repairing {des ribe)=--------- ----------------------------------------------------------- = ,_ ------------------•-----=---------•------ ; t 1 hereby certify at I have prepared this application and that the work will.be'done in accordance with San Joaquin County --------------------- ------- q ordinances, State Yw nd rules}n regulation of the San Joaquin Local Health District. t . _ -. ---- -_ _(Owner and/or Contractor( I ed)----------... - ------;--- -------- - '� ---------------- ----------------- U (Sign , ---•---- # (Title BY= k [Plot plan, showing size of lot, location of syste . ��relation to ells, buildings, a ftc.., can b placed on reverse side. # FOR DEPARTMENT USE ONLYr DATE------------------ Q APPLICATION ACCEPTI D 6Y---}- ------------------------------------ - f , ---•------------------- --------------- REVIEWED BY--------------------------------- ------------------ = - DATE J 9 f ----------------------------- - - ---- ------------------- DATE BUILDING PERMIT ISSUED------------------- -------- ------_-- -_-- Alteratand/or recommendations:.--------------- ---- -- - -------- - --------- ------------------------------ - Z-------- ions ” =f - --------- ------------- ......' ----------- -------- r ----------- ------ ---------------------------------- ---------- 4---------------------- ---------------------------•-------------------------------------- --- Date------. FINAL• INSPECTIONBY------ ----- ----- - SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y' ES--4-2M Revised 1.57 F.P.CO.