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Permit No. No. APPLICATION FOR SANITATION PERMIT Per (Complete in Duplicate) Date Issued ica-"ion is hereby made to the San Jo Local Health District for a permit to cons rust and install the work herein described. < This application is made in compliance w' unty Ordinance o. 5 9. A� JOB ADDRESS AND LOCATIO -- Owner's Name-----------!/`i�` ----------------------- - ------------------- ------------ Ph ne Address %tel''_ 1- -----. � `-44 '------- - � - ----- -- -------- - - -- ------ y� Phone_ __ Contractor's Name-------- ,� G� Installation will serve: Residence [Apartment House El Commercial El Trailer Court ❑ Motel ❑ Other E] ' Number of living units: I---- Number of bedrooms._ Number of baths _/__- Lot size ___�l__`j'_ +�,.:;- Water Supply: Public system 1771 Community system [-IPrivated epth to Water Table/ ft. Character of sail to a depth of 3 feet: Sand E] ,Gravel ElSandy Loam ElClay m 11 Clay ❑ Adobe �ardpan E] a Previous Application Made: Yes E] No New Construction: Yes ❑ No ❑ i.� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ss er is available within 200 feet.),, Septic Ta k: Distance from nearest well "`-.Dista ce from foundation__ �..�-____.MateriaL_____ __.__ ------------ ---- _ -Ca acit �t3�------ No. of compartments--- ---------------Size_ _G7__ -- -------Liquid depth_ 17------ p Y --- X m r_._.Distance to nearest lot line___ Disposal Field: Distance from nearest well-4e----- Distance rom foundation________ _____ Number of lines----/----------------------------Length of each.line---I`° ......----.Width of trench_ .".-_--•-- Dista f filter est ial--------------"---- Depth of filter material___.______:._____.__Total length___________________"----------__--- Yp � /`_ B�_.__.D t c� to nearest lot line-Y.-J.----- Seepage Pit: _Distance m f undation___ ____._.__ Number of pits--- ----------------Lining material---- ----- -----Size: Diameter__.-�--------Depth---�-�--'�----------- iCesspool: Distance from nearest well________________ Distance from oundation____________---..__.Lining material__._______.._-_._______________--_.. ❑ Size: Diameter-------- ---------------- ------------Depth------ ----------------------------------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building---"-------------------------------------- ❑ Distance to nearest lot line-- -------------- ---- ----------------------------------------------•---------------- � 4 Remodeling and/or repairing (describe):------ ------ - --------------------------------------------------•-------------------------------------------------------- I ----------------••-----------------•-••-------- ------ - ------------------------- --------------- ----------•---------------------------•--------------------------------------------------•----------------------------------•--------•-------•--------- I herebycertifythat 1 have prepared this application and that the work will be done in acc rdance with San Joaquin County ordinancS, e laws, anc[DAgg tions of +he San Joaquin Local Health Dis#ric+. Septic'Tank Servic^(Signed)- -----T'206,$*,ZWcrtidcz-__H0"7,-7`i1206,$*,ZWcrjadc�__H0-7,-7`iW------------------ -- ----- 9v n Contractor) " Stockton, Calif. Title _ By:----==---------------- - --- --------( } �sa c-�-- (Plot plan, showing size of lot, location of system in relation well9- rgs, et ., can be placed on reverse side).. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE_3�r7----------------------------------------------------- REVIEWED BY •-------------------- ------------------------ --------------------------------- DATE__ =A--- r.J ------------------------------------------- BUILDINGPERMIT ISSUED---------------------- ------------------------------------------------------------ DATE - ------------------------------ ... A Cera+ions and/or recommendations----------------- --------- • - -------- -- ------- ----- -P -'`' f Y - f-- -- ---- 3 - -------------------- .-- - > - _.._ r ----------------- ------------------ ------------------ --------- w._g---- , ------------ _ ------- _._ __ :? ° : ��-___:__:-------- ----- •------------------ ------------"- ------ --------------------------:------------ , " � 1l � FINAL INSPECTION BY.- Date.. V C./t - - ---- -----L _ -------- 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 W-2100