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APPLICATION FOR SANITATION PERMIT Permit No. .__ (� (Complete in Duplicate) S�y 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 No. 5 9. a - JOB ADDRESS AN OCATIO a - _ -------------- --' --- --------;----- -- Owner's Name__.- _-- -,-t_-_- ° _`IL-7 _, ------- =' ' Address ------- -- Contractor's Name.__ r _---- Phone hon ------------- - Installation will serve: Residence Apartment House;❑y Commercial ❑ Trailer Court E] E]E] .,Other E] Number of iivirig units: _-_ umber of bedrooms _ Number of baths I_____ Lot size___ __ __ __ _---_--_------ ------------ Water SuPPIY� Publics stemu -Co�mmunifY s stem'❑ Private ❑ Depth to Water`Table --- Character of. soil to a�depth of 3 feet: Sand.❑ . Gravel ❑. Sandy Loam ❑ Clay Loam E] ay ❑ Adobe.�Hard' ❑ I Previous Application Made: Yes ❑ No 2"" New Construction: Yes [?"�No ❑ FHA/VA- Yes ❑ No.O TYPE OF INSTALLATION AND,SPECIFICATIONS: I ' " I (No septic tank or cesspool permitted 'f publics er is'available within 200 feet. _ Sep,t�ic,/Tank: Distance'from. nearest welpistance from oundaion__.[_Cf.wl�aterial _ L� Y.i�lo. of compa.rtments----_----- ----=----- Size_ -- - - c ---Liquid. leth------- { Ca a ,,p� pcity_ � Dispos Field: D stance fromi-nearest'well._. ' ` Distance from foundation/. Distance to nearest lot I'njQ �I` Number of lines________ cf4:JL� Length of each dine_______.- �_ F_# - Width of.trench- _.__ i __ _ € `Type of'filter�materi�liDepth offilter, material___ _ __�_ _ - _ ----Total length _ i. _ { Seepage Pit 'Distance to nearest WO ` "�_�`Distance from foundation__ __'.Distance fo nearest"la,t line_ z ❑ ' Number of pit's I ___:Lining material___-- Size: Diameter_ ._ _Depth e: - t._ r --------------- ------------------ Cesspool.' -- Cesspool Distance from nearest well__ -------------Distance from _foundation___._._: --------"Lining material__________________._____'_- ❑ Sizer Diameter , rt -- - th --- -i---- --------- Liquid Capacity-,...--------------------------gals. Privy: Distance from nearest wel-------------___F_1________ -- ----- T._ Distance from nearest building'----------------------------I----------- Distance to nearest lot-line-- -------------- ---- . _. ._. Remodeling and/ar,repairing �d scribe): _ =I ' ---- ----- r-t-I i ---; ---,.-------------•-- ----- ------- - ---- -- -- ----------•---•---------- - ----•---- ----------•-------------------- ---------- } } _------------------------•-' --------------- ------------• --___---------------------- -.. a.. I hereby certify that'1 have"prepared this application and that the work will be-done in-accordance with San Joaquin County ordinances, State laws, and rules and regulations of fh San Joaquin Local' ealth Di i i (Signed)------- ----- ---------------011- `! M ------ - EOwner and/or Contractor) . --------------- ' =----- �� B Y- 1 f t ------ -�- -----(Title)----------------------±--------------------------- ----- (Plot .plan, showing size of lot location_of s stem in relation to wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-� + -` ' ' - ---- •------•--• -. DATE REVIEWED BY----------------- ------ - - . .., . _ = _ --=--: DATE:_ s-:. . _-- . i - BUILDING PERMIT ISSUEDDATE----------•--------_--'------- --'------ --- -•--_----- ----'-- ----- Alterations and/or recommendations:__.;-----------------------------0.____=•_--- �..�. ----------------------- -------- - -- ----------- ---- --•-------------- --------_--------•--- - ---------------------------------- ------------------------•----------------------- - - -------------------------------------------------- 1. •-----------------------------�------------------- ---------- = - - . -------------------------------------------- i -� . t. J r FINAL INSPECTION-BY:-7= = -_- --- - ' Date = =------------------------------- SAN - `= _ � - --------- 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-9-21f Revisea 1-57 F.P.CO. I,