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APPLICATION FOR SANITATION PERMIT Permit No. __ ............... i { (Complete in Duplicate)_ 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 incompliance with County Or ' nce o. 5 f JOB ADDRESS AND LOCATION... - ._- --- ------------- - /*10 /V I a Owner's Name -- --- 1 ----- --------------------------------- Phone_;v_ , > t , , -------------- -- _ Address 4 q ` ---------------------I------ - ' Contractor's Name---- ------------ -------------- �_...... ---- --' --•- •---•• ----------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ l' ❑ ' Number of living units: ____',C Number of bedrooms_� Number of baths :_�__ Lot size _____�&� ��e0`�_..________________ I� Water Supply:'"Public"systemC mmun fy'sysfern`❑'""Private'❑'"Depth to Water Table t. Character of soil to a depth of 3 feet: Send [:] `.Gravel I] Sandy Loam ❑� Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes 0 NoS` New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS:'=( ` (No septic tank or'cesspool'permitted if public sewer'is available within 200 feet.) 42yX4TaQ Distance from nearest well________________Distance from foundation---------------------Material------__________..___________:__________•._. 4 No. of compartments----------------------------Size.....-------------------------t:-Liquid depth-------------------- Capacity- ------ spo Fie3d: Distance from nearest well-____.._..____-Distance from found ation--------------------D7 sfdnce to nearest lot line----------------- Number. of lines----- ;--------------------Length of each line..-----------------.........Width of trench...--.....-_------._-- . . 1 Type of filter material----------- ----- ------- epfh of filter material-____________._.______Total lengths-------_______________________.__________- Seepage'Pit: Distante-to nearest}well- -__ Distant m_fofdation__c_ -_.�-.___.Distan�e to`nearest lot line_-_S___�____ Number of pits___.-_--------------Lining material__ _ ._Q'�. Size: Diameter____c � -__ p �_ - ---- .De Depth . _ r ---m- -- _ . Lining material-------------------------------------- Cesspool: Distance'fi•omnea ---------- D - - _ _ ❑ Size: Diameter` Depth ) ------------- -------------Liquid Capacity--------------------- -----gals. d Privy:, Distance from nearest we]-----------------------------------------_------__Distance from nearestfbuilding__________.________________________-___. [] Distance to nearest lot li6e- --------- - * I I ------ ----------------------------------- Remodeling and/or repairing {descrihe�: - =--------------------------'--------------•--------•----------••--------••------••--------------------------------------------------------- I �. { -----------------------------•------------------------------------------------------------------------- -----•---------------------•-------------------------------------:--- -------------------------------------.------- z.. � I a t' � -----•-------------•:-•---•--•---------•--------------------•---•------------------------------=----------------------------------------- :. -t------------------ ----------- ------------------------------------------ - I hereby certif that I have prepared this applicafion and{thaf fhe work will be done in accordance with San Joaquin County ordinances, Sta a la and rule am gula#ions of the San J.aquin Local Health District. [Signed)----------- { wrier and/or Contract r) �]�S.r�� By:------------------------=-------•-••---..:.vim-- ------------ -- -----.: .----........._..............._..{Title]._.........._... ...'._:.---.._...--•---•------------------------ {Plo# plan, showing of lot, locetion'of system inirelko o wells, buildings, etc., can be placed on reverse side). ' 1 f ! 4 FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY----- - ---=-------------------------- DATE-------------------- � REVIEWED BY------------------------------ ----- . = _»_ - l-•____ _ --------------- - DATE------� - --•---------------•------------------- r --- ------------- DATEBUILDING PERMITISSUED--------- Alterations and/or recommendations:__ ------- ---------------------------------- ---•-----=------------------------ ----------------------•-----------------•------------------- ----------- ------------------------------------7-------------------------•--•-----------•-----------------------•------------ -----------------------------•-••--------------------•----------- --•----------------------------------------------••-------•----------------------------------=------------•------------•----------------------------------- ----------------------------------------------•--------•----------`-------------------------------------------•--------------------------------------------------------------------------------------------------------------- i ------------ FINAL INSPECTION 'BY.-/- -- _ __ - '- - - - - -- -- — - - Date-. = = ' SAN JOAQUIN LOCAL HEALTH DISTRICT 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.