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f5 e {1APPLICATION FOR SANITATION PERMIT Permit No. __ _�Z__.. ,� (Complete in Duplicate) T 5 5� Data Issued :7/ F1_z i 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 y Ordinance No. 9. JOB ADDRESS AND L TION. = `" - - '� '�--------- P-1 ------ Owner's Name--- - - --------------------------------------------------------------------------------- -- ------------- Ph.- - t Address__ ------ I Contractor's Name_. _V - �'�-� ----------------------------------- Phone------------- ------•-------------- Installation will serve: Residence �partment House ❑ Commercial E] Trailer Court ❑ Motel [__1 Other ❑ Number of living units: .._ Number of bedrooms _ __ Number of baths __ _ Lot size __- ? � Water.Supply: Public system Community system El Private E] Depth to Water Tablee- "ft, __ _ __________________ ` Character of soil to a depth of 3 feet-, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ i Previous Application Made: Yes ❑ No New Construction: Yes [j No FHA/VA: Yes ❑ No i , TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) /o Sep Tank: Distance from nearest well_________________Distance from foundation_-_----------------Material----------_._______.____.__-__________-______--. U 'No. of compartments--------------------------Size--------------- ----------------Liquid depth--------------------------Capacity--••------------- f Dis Field: Distance from nearest we€I---------------:_Distance from foundation--------------------Distance to nearest lot line_______-_______- ti Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------ ---------- f4 sI w . Type of filter material-------------------------Depth of filter material____-___._-__.______--otal length--------------------- __-__________-_�. epage Distance to nearest well- --Distance from—fou ation___��_.D'st nce to nearest line ------.____ v Number of pits___.__------------Lining materialC _�!_ / F.. rr ---- ----size: Diameter Depth � , Cesspool: Distance from nearest welL________________Distance from foundation---------------------Lining material_________________.. ❑ Size: Diameter------------------------- ------------Depth----------------------------------------------------Liquid Capacity-- ------------------------gals. , IPrivy: Distance from nearest well---________________________________________"-.._Distance from nearest building________-__-_---------------------------- ❑ - Distance to nearest lot line,. - --- ---------------------------- ------ - ---------------------------- ----------------------------- . I Cl I ----------------- Remodelingand or re airin descr" e --------------- ,,,�_/ i / P g f >r�r y --------- '` Jf.�F.��T V ------------------------------ ------ ------) -------------- -- --------------------------------------- ` ---- ------------------ ----- -- - I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health district. F; (Signed) -"- • --- •- -------------------------------------------------------- --------------------- ----------------------------------- ------(Owner and/or Contractor) ___Title (Plot plan, showing size.of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I -FOR DEPARTMENT USE ONLY I ' APPLICATION ACCEPTED BY-------- ------------------------------ ---------------------------------------------------. DATE--------------• --- �-- -------,--------•-------------- � i REVIEWED BY ----- ----- DATE-- .....--. 1 BUILDING PERMIT ISSUED------------- ----------------------------- - ----------- ------ - DATE-------------------------------------------- --- Alf s and/or recommendations:______ �_. a�n 1 .. � -------------------------------------------------------- -------------- -----� --------------------------------- _______________________________________________________________________ _____________________________"_____.__________________--.--------.---------------------------------------».---------------------------------------- --------------------------------- _ _ --------------------------------------_------------------------_-------------------------------------------- -------- FINAL INSPECTION BY::_ - ------ Date__..._ ---- -1 AN JO QUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P,CO. t