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�-� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �f Date Issued __ ..�� Application is hereby made to the San Joaquin Local Health District for a permit o construct and install the work herein described. This application is made in compliance with County Ordinance No. 54,9.<' JOB ADDRESS A D LOC ION U -'3 " ' ' I- -----------------------------------------6 „J."7C � VOwner's Name - - ^ --------------- ----•-- •------�--} -----• Phone---------- ..................... Address--------------- --- -- - ---- - ------- Contractor's Name---- ---- ---- — -i --------------------------------- ------------------------------------------------------------.-- Phone--------------------- ------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ `f Motel ❑ Other ❑ Number of living units: _j-____ umber of bedrooms ---Z Number of baths --1---- Lot size ___K"- X__j --------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table ________ ft• Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam ❑ Clay ❑ Adobe 9'-"Hardpan ❑ Previous Application Made: Yes ❑ No I/ New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No P . P permitted �„�/_ -_______ Dista ce om f thin 200 fee#. �. Septic aokse tic taDlistanceor sfromf nearer ell_" s Diremwer �s ce tr available oundatjon��J__ +Material_�Capacity- i'i _ f____.__-___.____: [� No, of compartments_____-- -x+--- -----`---Size- -U------- - -------- - iquiidd depth-------------------Disposal Field: Distance from nearest wel -_--, 0-+`Distance from foundationll -,_ 1Distance to nearest lot li 91� Number of lines-------.__rr �J--__-_r__L�ength of each line________-s�0_�_rf----'440-r-4-Depth length________________! -------- Type 441 Seepa Pit: Distance to nearest wffell_- _f4 _Distance m foundation--------------------' Distancq to nearest lot line___t Number of pits---------A----------Lining material----1��ize: Diameter_--___•�3-_--___-Depth____--_(6--�______----____ Cesspool: Distance from nearest well-------------....Distance from foundation--------------------Lining material________-_-_--_________-__-_-__.__ ❑ Size: Diameter--------------------------------- - Depth-----------•--------------------------------- --Liquid Capacity............• --------------gals. 4 Privy: Distance from nearest well---------------___--------_----------------------Distance from nearest building____-_____.-_---------__________---_--_-- ❑ Distance to nearest lot line---------------- Remodelingand/or repairing (describe):------------------ ------------------- --------------------•-------------------- --------------•------------------------•------•------------------ /f ? _ -- --------------------------------------------------------------------•------ --------------- I hereby certi,y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances0y. St f aws, and rules,-and regulations of the a J quin Local Health District. (Signed)----- •--P�.---- --- -- =----------- ------ -- ------ - ---------------------------------------------------{Owner and/or Contractor] By:------- -----•-- ---- •---•- ---- --- - --- ---•----- - -----•----------------(Title)---------------------------•------------------------------------ (Plot plan, shof t, ocation of system in rela ion to wells, b - ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------- DATE10 -•---•--- REVIEWEDBY----------------------------- --- ---- --- - -- --- --------------------------------------------------------------- DATE-�--------------------------------------------•- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------- Alterations and/or recommendations------------------------------------------------------•-----------------------__-__-•--•--____----•----------•--------•-------•-----------------------------•- ��_ ------------------------------------------------------------ -- --------------------------- ---- Or _-- ---------- -------------- _______________ ___________________________________---___________-__- ----_--_--_-______--__________-____---_--______________________------.-__ -___.-_________-__._-________________-___-___-___________--_-_____ FINAL INSPECTION BY:-------so"--//------ ./� Date �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oal: Street 132 Sycamore Sfraet 814 North "C" Street Stockton. California Lodi, California Manteca, California Tracy, California ES--9-2M , Revised 1-57 F.P.CO.