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APPLICATION FOR SANITATION PERMIT Permit No. *N '*--(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 No 49. JOB ADDRESS ANOCATION------ ---- ----- J------- -- - ---- --------------------------- ------- --- - I---------- - Owner's Name-.,. ----------------- -- -------- -------------------------------- -------------- Ph ---- ------- Address----------------- 1 --------- ------------------------------------------------------------------------ ---------------------- Contractor's Name--------- ----------------- -----------j(-- ---------------------------------------------------------- Phone- ---- Installation will serve: Residence Apartment House Ej Comm4cia[ F] Trailer Court [-] Motel Other ❑ Number of living units: Number of bedrooms j5t- Number of baths QZ__ Lot size --------------------------- I Water Supply: Public sysfem .F] Community system 0 Privatex Depth to. Water Table,4!�_�ft. Character of soil to a depth of 3 feet: Sand E] Gravel [-] Sand), Loam 0 Clay Loam E] Clay E] AclobHardpan E] Previous Application Made: Yes El N,,Z New Construction: Yes X No El FHA/VA: Yes F1 No�' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) aLep t i c 4Tn k: Distance from nearest well---6-------------Distance from foundation--------------------Materiai-------------- ---------�Z ---------- ---------- No. of compartments---6-----------------------Size---------- _1-•----------------Liquid depjh.---- --- ---- Dispos ield: Distance from nearest well_________________Distance i��foundation-----_-_.-----.-----Distance to nearest ]*of line-----K------- Number of lines-----------------------------------Length of U�eadh line------------------------------Width of trench------------ --------- e- Type of filter material-------------------------Depth of filter material___.__------------- otal length-------------------------------I-------- D�sfance to nearest well__1,?'1A__1 m a io Distance to nearest Icit-lin ----------- SeepQqe Pit: ------Distance �—ro4funcl f, Number of pits----f.---------------Lining material_,p—,P-zVrt------Size: D! eter___,_7e............Deplh-' sme-10.,11 -- ----------- Cesspool: Distance from nearest well.................Distance from foundation....________-7 ---.Lining material_-----.-.-.--------------.._-i ----------- C148" 11 1 Size: Dia,meter------ -------------------------------lDepfh---------------------------------------------.-J-.-Liquid Capacity----------- -ga s, Privy: Distance from nearest well---------------------------- ...Distance from nearest building---------------------------- -------- ❑ T - ------- ----- *- ____ t I -------------:- -------------------------------------------------------- Distance to nearest lot line------------------------------- ---------------------------- ------ 'ne be):. ---- --- ------- Remod( �pr_repairing (clescril - ------ --- - ------ --- -------------------------------- --------------- ----- ---- ----------/----------------------------------------------------------- ---------------------- ---------------------------------------------------------------------------- ----------------------I------------------------------I------------------------------------------------------------ � i -----------------------------------N-- ----------------------------------N-- ----•------------------I --I----------------------------------------------------------- --------- - ------ }hat -------- -- ---------- - - ----- __I hereb_y_-_6e_rf_4y__ _. 1 .--�-)-repar-e-d--fhis-ap-p-l-i-catio, nd the the work will be done -in accordance with San Joaquin County ordinanidCs, State laws nd rule ad regulation of th n Joa in Local Health District}. Owner an,�/or Contractor) ISigned --- - _ -- ---- - ----- ----- --- ----------- ---- ------- ------------ fle - ------ ....---------------- By: --- -- ---- --------------------------- - ------------- ------- --------- (Plot plan, sh in six a lot, ocati sysf e in relation to wells, buildings, etc., can be��ed an rev rse e). FOR DEPARTMENT USE ONLY ------------ APPLICATIONACCEPTEDABY------ ------------------------------------------------------------- ------------------------------- REVIEWEDBY------------------- -1-------------------------------------------------------------------------------------------------------- DATE------------------------------------- i------------------ BUILDINGPERMIT ISSUED'--.--.------------------------------------------------6---------------------------------------------- DATE-1---------------------------------------- ------------------ Alterafion; and/or.recommendations:.-- ----------------- ---i--------- ------------------------------ --------- ---------------------------------------------------------------------- -1) J ---------------------------- ------ ----------- _F�_PTH------------215- ----------- ----- ----------------- ------------------- --------- -7-7--------1 ------------------------------------i------------------------------------------- ------------------ ------------------------------------------------L--------------- ------------------- ----------------- ----------0-A----------- `-------------------------------------------'-;--------------- i -- -------------- ----------------------------�:------------- _4 ------------ ---rVV ------------------------------------------------------------ ---------------------•--------------- ------------ ---- ------------------ Date.---------- --------------------------------- 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-9-21x1 : Revised 1.57 FP-M