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APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicatel � This Permit Expires 1 Year From Date Issued Date Issued ' Application is hereby made to the San Joaquin Local Health District for a permto construct and install the work herein described. This application is made.in compliance witlalCounty Or i a JOB ADDRESS AND LOCATION- � °-----_-- Owner's Name z_ l t a --- --- ------------------------ --- ------ ------------------------ --------- hone-- Address-----------------------4,26- L-gE, Contractor's Name --------------------------------------------------------- -------------------•-----•------- Phone----------------------------------- Installation ------•--------------------------- Installain will serve: Residence. Apartment House ❑ Commercial I-] TiCourt El Motel Other ❑ Number of living units: _/i____ Number of bedrooms __ _ Number of baths _-.r__ Lot size ----'1;7- �______________ Water Supply: Public.system W Community system ❑ Private ❑ Depth to Water Table -------- ft. ,Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®' Hardpan ❑ Previous Application Made: Yes J� No)N, New Construction: Yes jW Noo FHA/VA: Yes ❑ No f 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-_ Distance from foundation____-Z2_______-Mater�l--_-____�arll t?----- -------------- r[ No. of comp'prtments----_-----�----------Size---";-I-_1 -_3h---��-Liquid depth-------- --------------Capacity-----o040.f_ Disposal Field: Distance fro nearest well_Aer! -_Distance from foundation._--fes"'____.Distance to nearest lot l e___c3��--- ® Number of limes----------- _Length of each line__________---StA-i__________-Width of trench-- _,�.? ______________.._ Type of fil#ee�maferial-F-ecu^.r____Depth of-Jilter material____._L9_ __-___Total length_____-_.06__L _-l________________ Seepage Pit: Distance to nearest well_:_________---___ Dista'nc�e'from foundation--_,:_.__________.Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------.----------------------• ry� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material________-___-------__-_______________- V ❑ Size: Diameter--------------------------------------_Depth-------- ----------- -------- Liquid Capacity----------------------------gails. Privy: Distance from nearest well------------------------------------ --------------Distance from nearest building___________-_________________..___.____. ❑ Distance to nearest lot Iine------------------------- --------- - . Remodeling and/or repairing (describe):---------- '-------------------- ----- --=---=•----------------------------------.-------------------------------- -------•---------------- ordinances, St to ._._-laws, and rules and redregthis a li the San Joaquin Loyal'will'- ______________________________________________________________________ nt Ihereby certify that I have prepared this application and that the work will'-6e done in accordance with San Joaquin Count h District. ' k � X (Signed) f - .R -- ------------------------------------------------ ------------------------------- wner and/or Contractor) By=---------------------_--------------------- ------------------- -----°---------------------------------------------------------(Title)--------- ------------------ ----------- � (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' r _ APPLICATION ACCEPTED BY--- a DATi �� C_. - - - ------ --- ----------------- REVIEWEDBY------------------------------------------/------ -------=------------=-----------------------------------= ---------------- DATE--------------------------------------------- --------------- BUILDING PERMIT ISSUED---------------------------------------------------------------- ------------------------------------ DATE - Alterations and/or recommendations:-------------------------- -- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------•--------------------------------------------------------------------------•--------- ------------------•-----------•--------------------------•---------- ------------------------------------------------------------------------=----------------------------------------------------------------------------------------------------------------------------------------------------- ------ FINAL INSPECTION BY: ---- `e -------------- Date l -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streot 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'59 r,P.cc.