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�647 APPLICATION FOR SANITATION PERMIT Permit No. ._._jl (Complefe in Duplicate) � T Date his Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit Jo.construct and install the work herein described. This application is made in compliance with County Ordinance No. 5 S JOB ADDRESS A ___- _ _ . - 3d0 Q.-.._ ------ .�- L - — 3 2- s Owner's Name. ------ --------- ----------- Phone.. .._.. Address----- ------- J ----- ---------------------- Contractor's Name-------- •------ :tel----=------ -------------------------------- -----. Phone----•---•• i Installation will serve. Residence X Apartment House ❑ Commercial .0 Trailer Court ❑ Motelj ❑ Other ❑ Number of living units: -L_.- Number of bedrooms ---t_ Number of baths -__ Lot size yy�� -----------•----------- Water Supply: Public system tK Community system [I Private g_ Depth to Water Table-&-- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam p Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No b— New Construction: Yes . No ❑ FHA/VA: Yes ❑ No k TYPE OF INSTALLATION AND SPECIFICATIONS: + (No septic tank or cesspool permitted if publici.sewer is available within 200 feet.) f Septic Tank: Distance from nearest we Dist e fromarterial-_?�_ "--_ (L No. of compartments- ----------------- ---Size_ .x �'�.---Liquid depth----- -- -- -. - - - -------- CapautY-----�-ESQ-�--f--..___ Disposal Field: Distance from nearest well___-.--Distance from foundati 10 Distance to nearest lot line Number of fines----- t --- --•-- � ---- ------•---�� { li_ - -.____ ___Length of each line_____-�a _ ___::____--Width of trent E Type of filter material- ii �a------------------------ --------------------- pth of filter material leng#h____" 0"__"- Seepage Pit: Distance to nearest well-_-_-----------------Distance from foundation--------------------Distance to nearest lot line----------- ❑ Number of pits----------------------Lining.material---------------------- Size: Diameter-------------- --------Depth.-------------------------. - Cesspool: Distance from nearest well-----------_-----Distance from foundation------------ _ ----Lining material_____---_ "---- ----------- 1 ❑ Size: Diameter-----------r------ ----------------Depth--------------------------------------------=-----Liquid Capacity-------------------- gals. , Privy: Distance.from nearest well______-.__."----_-__I..._._" ___________________°-Distance from nearest building.____-.-_________- ,stance to nearest lot line---------------- ------------------ ------------------ -- Remodeling and/or repairing (describe)____________________ ----------------------------------------------------- -------------------------- ---------------------------------------------- ---•----------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations the San Joaquin Local Health District. C(ra or) w e r / (Ti+le (Piot plan, showing size of lot, location of s'gstem in relafio o wills, buildings, etc., can be pla'ce6 on raver a side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------"-_-- :- ---- - DATE---------- -------- --- ---- --- -- --------- ------------------------------------ BY------------- --------' ------ DATE----" p, ---- -- ---- -------------------- -------------------------• 1 -- --- --------------------------------- BUILDING PERMIT ISSUED ------ DATE------ - - ------------------------------------------- Alterations and/or recommendations-------- ------ ------------ ---------------- ---------------------- --- !.: --------------------------------- ---------- --------------------------------- - -- - - ---- � ----- --- ----------------I----------------------- -- ----- ------- ---- 1-7-AV G-------------------------------------- -------------------------------------------------------------- ----- FINAL INSPECTION BY:-- ,-____ -- _- Date --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streot 132 Sycamore Street 814 North "C" Street Stockton. California Lodi, California Manteca, California Tracy, California P ES-9-2M Revised V59 F.P.Co.