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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 1 This Pei mit Expires ] Year From pate Issued D/ (to Issued -___�_- t 4 `f —(s— Application is hereby made to the San Joaquin Local Health District fora permit t o truct and install wo k here' des ibed, This application is made in compliance with County Ordinance ] X1 A ADDRESS AND LATION.___ �''� 1'r_ - - ---- ------- ---- ------------ -- -- ----- ---- ------ ------ Owner' s Name______ :----_ - - - ---------------------------------------------------13-1x--)d---7 . ,Phone Address tr � � � /------- ---- �9�3 Contractor's Name ---.----- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l___ Number of bedrooms _- _ Number of baths __/._ Lot size _ p--- Water Supply: Public systemCommunit system y stem ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel`❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe-�ardpan ❑ Previous Application Made: Yes E] No ZK"New Construction: Yes (�Klo E] FHA/VA: Yes [K]�o ❑ 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___�Q_/___.-_Maf1rial-( -��.- ' ------------ P �' `' Ze- -- -- Q Liquid depth Xt -----Capacity--��l)------- Disposal �.. F' Distance from nearest well______ ____ _Di o. o compartments _____________ __ Si rr �- `�`' 'stance from foundation_'�_��_ __._.Distance to nearest lot line_-�_v�____ W ' Number of lines___.__�_ ------ Length of each line---____R�-�------ ----Width of trench.- ---------------------- _/;t ------------------- --- �1 See a e 't: Distance toenearestlwel/��D scan of friltrerfoundritil ---/�' -'---Total length_-_,__�,0__________________________ P g a on_-.tZ-O.....-_.Distance to nearest lot line-_�:�_-______ Number of pits.-'-/-------------Linin material-- -&V</e Size::Diameter__,?2_'__-.---- Cesspool: Distance from nearest well_________________Distance from foundatio -_.___-______--_ Lining material-_.___--__.._______.__-----_____--__. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity------------------------- gals. Privy: Distance from nearest well---------------------_____________ M ¢ a .---._-__.._bistance from nearest building._-___._______._______-________----.--_-. ❑ Distance to nearest lot line-- ------------------------------------------- ------ ---- --- Zi Remodeling and/or repairing (describe):--------------- --- �W, _:_ ------------------------------------------------------- ---------------------------------------------------------------------------- ------------ ---- --------------- ------- ---------------- -------------------------- ------------------------------tz------------------C------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r es and regulations 7of the San Joaquin Local Health District. (Signed)---------------------- j � /L l--- ----�._ -------- --------------- ------- ----�o By:------------------------------------------ - `I - � r Contract - r ••--------•--------1--- - (Title) (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). .� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- DATE---------rJ----" �f REVIEWEDBY--------------------------------------------- ------------------------------------------------ ------------------------------ DATE------------- -------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------- ----- ---------------- DATE --------------- aerations and/or recommendations------------------- -------•------•------- -•------------ „ - f . - � �= - ` ~-------------------- ------------------------------------------- ------------------ ---------------- --------- , � r FINAL INSPECTIONBY:.__ _-_ ---.. .- Date__.-- - -�-� .SAN JOAQUIN LOCAL HEALTH DISTRICT r\ 130 Soufh American Sfroet 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ;� Lodi, California Manteca, California Tracy, California FS-9-2M Revised 8-'59 F.P.Co.