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i APPLICATION FOR SANITATION PERMIT Permit No. lk�EA (Complete in Duplicate) - Date Issued Application is.hereby made to the Sam Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AND LOCAON �j Owner's Name-------- 1• � h r t------------- -------------------------------------------------- ----------------------------- ------------ Phone------------------------------------ Address - 4 ------•---------- --------------------------------=-------------------------------------------------------------------- Contractor's Name -------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence jr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _!-__ Number of bedrooms-6. Number of baths _ __ Lot size _ _, __ Z ------------l _________________ Water Supply: Public system 9KCommunity. system ❑„ Private ❑ Depth to Water Table '0"ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ 'Adobe[Hardpan ❑ Previous Application Made: Yes ❑ No 99`� New Construction: Yes M'--No ❑ FHA/VA: Yes o R�_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well -r`-------Distance from foundation---/,-----•- --.Material__eW_"i- --t`-0,dd- No. of compartments . [� p *�'-- - .� � -�-- ---------Size-- --- -- �--Liquid deR�h---•-,--------------------Capacity....1',�-�-�-- Disposal Field: Distance from nearest well----�"r-----.Distance from foundation----A0--------Distance to nearest lot line_. ._i.... T e of filter materia_,��•�-_` __-De hof filter materi��.c�-°'____._Total hfrench__ _�or_________________ Number of lines______________�--------_ Length of each line___ Yp ,� P length. ----------------------- Seepage Pit Distance to nearest well-- _____Distance fr m f undation_ __ __.Distance to,nearest lot line----- ---- Number of its____ ______ ___Linin material__ Size: Diameter_-. ._r� P g - Depth - - - Cessp ol: Distance from nearest well------------...._Distance from foundation------------______-Lining,material_______-___________.__--_-____-____. ❑ Size: Diameter----------------- --------------------Depth----------------------------- ----------------------Liquid Capacity_--------------------------gals. Privy: Distance from nearest well____-_______________________-___________-____Distance from nearest building---------------------------_______-___--. ❑ Distance to nearest lot line----------------------------------------------•------------------- Remodeling and repairing (describe):_--'-_--"____ 4.�✓' �� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 40 ordinances, State laws, a d rules and regulations of the San Joaquin Local Health District. ,. (Signed) - ------------- ---------- r Contractor) By: = -� Z_ _ --------------------------------------(Title) I�'L ------ (Plot plan, showing size of lot, location tem in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ------------ DATE---=-- REVIEWEDBY - --------------------------------- ---------------------------------------- DATE--�-------------------------------------------------- BUILDING PERMIT ISSUED-------•-- - - ------------ -------•-------------------------------------------------------------- DATE------V� Alterations and/or recommendations --- ---t------------ -------- ----•--------------------------------- ---- 'i' P�tN ----------------------------------------------------------- ------ ---------------------------- ----------------- - - FINAL INSPECTI.ON BY:._-_ .__ 1- _ __A _____ ________ --__ Date--------- � 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,CO.