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APPLICATION FOR SANITATION PERMIT Permit No. , Q -_ (Complete in Duplicate) This Permit Ex ires 'l Year From Date Issued Date Issued'____:� •��/ _ 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 Co my Qrdinance No. 5. 9. t JOB ADDRESS AND LOCATI N _�" or -- Owner's Name______ _."-_t__ - --------------------------- Phone Address ............ ------ ---- -- ------ --- ----- Contractor's Name T -- ------- ----------------------- ---------- -------- Phone. Installation will serve: Residence [3} Apartment House ❑ Commercial ❑ Trailer Court ❑ YMotel ❑ Other ❑ Number of,living units: __.I___ Number of bedrooms _3_-_ Number of baths --___ _ Lot size .". Water Supply: Public's stem ' "_/ Y Community system ❑ Private I] Depth-to Water Table �0 ft,.. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ` Previous Application.Made: Yes I No y ❑ ,Clay Loam ❑ Clay ❑ Adobe [g—Hardpan ❑ ❑ ) 9l- New Construction: Yes No 0 FHA/VA: Yes ❑ No E-- TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well +rpt/'''-�.-.__Distance from foundation---�l------------_Material------I L�- - -----------•--- ----- ------ No. of compartments__--�---,1 -------_-Size__-LRCS-[ y� Liquid depth-------"f--------------Capacity-- fJ0 -4 Disposal Field: Distance from neares well-___'____-____.._Distance from foundaticn._/Q_�- pistance to nearest to#�ine _t _..___01 __... n Number of lines........ _..__ _ -------------------Length of each line__." --_.- Width of trench__-._.3-_----- "L Type of filter maferial_ p_('/ -_--------Depth of filter material___9ff--------------Total length----f� ------•------------- Seepage Pit:' Distance to nearest well------�__----_-Distance from fo ndation-___10�-Distance to nearest lot iine-_.� � "r,rW Number of pits__.�,l----------Lining material_'-kOX / _Size: Diameter--.,/ -----Depth.......� Cesspool: Distance from nearest well______ - -- ___________Distance from foundation_--.__--__--__--._.Lining material-----._.___-____-_..-____-_________. ❑ Size: Diameter--------------------------------------Depth_-------------------- -- Cl1 - - -- ------- -------- --Liquid Capacity ----------------- --------gals. ' Privy: - Distance from nearest well---------------------------" Distance from nearest buifdin El Distance to nearest lot line------------- g-- �------ ------------------------------ --------------------- -------------------------------------------------------------:--------------------------------------------- Remodeling ---------------- ---------------------- ---------------------------- Remodeling and/or repairing (describe)-----------------------------_ - - �, ---------------=------- - -`---------- - ----------------------------------•-------------------------------------------------------------------------- ---------- --------- I hereby certify that I have prep un ed.fhis application and that the work will be done in accordance with San Joaquin Coty ordinances, State laws, and rule. an regulaii ns of the San Joaquin Local Health District. (Signed)------------------------ ---- ---- --- -------------- ---;_-_--.___Owner and/or Contractor By: --- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). �1011,00�ARTKAPIJT USE APPLICATION ACCEPTED BY____._.-_ '" "."" ------ -------------------------------------- REVIEWED BY--------- --------- DATE------ ---- ------��-----�� --------------- -------------------------------------------------------------------- ------ DATE------ --------------- BUILDING PERMIT ISSUED. - ---------------------•---------- -------------------------- DA•TE.-------------------------------------------------- A terations and/or recommendations:__-_!_..__. -`__.__--__ ----------------- ----- ----------------------- - FINAL INSPECTION BY:.___ /0 ------ - --------------------------- ---• -------------- -- ---------- - „ - ate -6-- _ - �C-- ------------------------------------ I SAN JOAQUIN LOCAL HEALTH DISTRI / y 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Man}ace, California Tracy, California ES-9-2M Revised 8-'59 F,p.Co. -