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., APPLICATION FOR.,SANITATION PERMIT Permit (Complete in Duplicate) � Date Issued __..-1i•G , 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 54 ,r JOB ADDRESS A °LOC t N � fs + ------- --- -------- ,-------------- -------------------------- Owner's Name--- -;--- Address = ' ph . - one.- '---------------------- i: = •- -----¢-------- Contractor's ame_- � ---------------0----------------------------------- - -------- - -- ------------ Phone Installation will serve: Residence L� Apartment House Commercial Trailer Court �k s� ❑ ❑ Motel ❑ Other ❑ Number of living units: __ --_- Number of bedrooms ._[ l _ ._ Number aths ___f__. Lot size ___ P-___- Water Supply: -Public system ❑" Co ' muriity sysfiem'❑ "Private Depth'to Water Table _ ----- ft: Character of soil to a depth of 3 fee+: Sand Gravel ❑ Sandy Loam Clay Loam Clay ❑ Adobe Hardpan ❑ M Previous Application Made: Yes ❑ No New Construction. Yes No [❑ FHA/VA: Yes ❑ No ❑ . + kt TYPE OF INSTALLATION AND SPECIFICATIONS: [Na septic tank or'cesspool permittedif public sewer is available within 200 feet.) ,5eptig Tank: Distance from nearest well_----------------Distance from foundation---:........ :.......Material ___-___'________________________________________ �ij No. of compartm"encs-----_---•------------ Size-------- - ----- -- -----Li d de t --------- - ----- ----Capacity F qP. P Y ---------- Id ---- �) Disposal Id: Distance from nearest weftFo5L9--.._.Distance from foundation_Pji __ ____ __ istance fio nearest lot line ?ii'f~►s � Number of lines---------- -----1 -----------.--_Length of each line-------_ -----it Width of trench---- ---/Fy 411 - T e of filler materi�- - r / YP l� ! Depth of filter mate ria Ieng+h____.___. ---..___-------_- Seepage Pit: Disfance to nearest well._.. —'--'-"---Distance from foundation------------_'_'_-__-.Distance to nearest lot line.____------------ ------------- #..______._ �� ❑ Number of pits._I__`____ - =___Lining material______________________Size: Diameter------------__._ -------.Depth------------------•-------- ---- R a o Lining material. --------------------- El esspoo : SDize�C)ia titer nce from neTarest�well-------------=---Des Depth from foundation_==-- ---- - ------Liquid Capacity___._____-_______----______galsQ , Privy: Distance from nearest well_______________________ --------------_----Distance from nearest building -----. C4 ' Distance to nearest lot line �- - 0 RemodelingAnd/or repairing [dg c ------------ ------------ ----------- "---• - - ---------------- --- - - -------- ---- -- ---------------------- --------------(4-- ... -- - - - - :----------- --------------- W ---- --------- A L-1 I hereby certify that I have prepsre'd this application and that the work will be done in accordance wi#h San Joaquin Coun+y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, [Signed)----4" Im t " ----------=�------------------------ -------------------------------------- � ----------------------------------(Owner r Contract -..., By:.------ w ------------------------------- ------------------------------- - Title ne and/or or- --- ------------------------------------- (Plot plan, showing.size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _` DATES - - - ----------- !!. ! ------------------ -------------- ------------•---- REVIEWED BY DATE_ _ -------------- --------------------------------------------------------- BUILDING PERMIT ISSUED----------------------------¢------------------=--------- - ---------------. DATE------ --- -- I --------------------------- Alterations.and/or.recammenda+ions_________________------------------ ----�------------------ ---------• ------•-••------------------------------- '--------`-"`----------------- ---------------------------------•------ --------------•--- ----- i --•-------------------------- - FINAL INSPECTION' BY: 7 L. — �� ' mak Date. -------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised 1•57 F,P.CO.