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^ APPLICATION FOR SANITATION PERMIT Permit No. _J -Y4F' (Complete in Duplicate) �/ w Date Issued --- ------ Application Application is hereby made to the San Joaquin Local Health District for a perr-jit to cons r ct and install the work herein described. This application is made in compliance with Count Ordinance No. 5 9 N= '32- -- a& o —O - - ----JOB ADDRESS AN L CATON----- ---- ----------------------- Owner's Name----- - ------------------------ Phone------------------------------------ Address...... ----------•-------- Address_---.. --------------------------------------------------------------- = --------------- ---------------------------------------- Contractor's Name------------------ --------- Phone. ------ `bgCE Installation will serve: Residence ❑ Apartment House ❑ Commercial `frailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size --- __ _ ___V __________________ I Water Supply: Public system ❑ Community system ❑ Private g?006epth to Water Table _ ,S ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[B--Mardpan ❑ f,1� Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No P-` HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permiffed if public sewer is available within 200 feet.) ank: Distance from nearest well_________________Distance from foundation__.________________Material------------------------------------------------- No. of compartments---- -----------------_Size--------------------------------Liquid depth-------------- Capacity---------------------- - 1 , If,;c psal Fiel Distance from nearest well J�_�....__Distance from foundation_ d______.__.Distance to nearest lot lin��'______._ Lam` Number of lines-------- _Length of each line__/-4--V ----------Width of trench.___, Type of filter material-51-RMID-epth of filter material_____,�g_ _----Total length______,!, '____� Seepage Pit: Distance to nearest well_ --�------Distance rom undation-------Q�'__._ istanc sio nearest lot line__._________ 0� Number of pits___-----------Lin'ing material_I - ___ �__.__-Size: Diameter____.y�'_______Depth------ _ __ ____________ ------------ Cesspool: Distance from nearest well_______________Distance from foundation--------------._.__.Lining mai-erial-------------------.____.-_ _-______. � '�'� Size: Diameter--------------------- ---------Depth------------------------- --------------------Li uid Capacity __gals. Privy: Distance from nearest well-__________________________-_______._.---------Distance from nearest building______-_________________________. ❑ Distance to nearest lot line__________________________________________________ _ Remodeling and/or repairing (describe):--------- -------- ----- ----- ----------------•----------------------------------=------- ------------------_-_-.------ -------------------------- ----- -------------- --------- ----- -------- ------- ----------------------------------------------------------------- ------------------------------------------------ I herebycertify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinanc laws, and rules and regulations of the San Joaquin Local Health District. w (Signed)--------- ---- -- ------ --- -----�-- -- - - - - -�----------------------------------------------------- ---------------------------------------------- - ---,�-i.----�-{Owner and/or Contractors By:------------ ------------------------------------ - --------------------------------------Title !/ (Plot plan, showing size of lot, location of system in.relat fo wells, buildings, etc., can be placed on reverse side). i. FOR DEPARTMENT USE ONLY �r APPLICATION ACCEPTED BY-------- ------------------------- ---------------------------------------- DATE_.-----6-r Z.. �C REVIEWED BY---------------&O-WARn------Ru-N—)0Aj----------------------------------------------------------- DATE---------------------------- - -------------- BUILDING PERMIT ISSUED-------------------------------------------------------- --------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-------- -------------------------t-------- ---------------------------------------------------------------------------------- 'i T 7 t 'H. *2 ON 1------Q_Al�---------�,a-------- -0t K---------�" ----------- Z4_.2 1-T---1)F__? l.k---------- -----------:2 --------------------------------------------------------------------------------------------------------------- AG` P,I ------------ --------- - --- --------------------------------------- 0- ! `'� 4'. ` � --------------------- FINAL INSPECTI 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 1 ES-4-2M Revised 1-57 F.P,CO.