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FOR OFFICE USE: ; APPLICATION FOR SANITATION PERMIT Permit No. ....L.-._:_......_., ------------ (Complete in Duplicate) -, G ( u -------- This Permit Ex fres 11 Year From Date Issued Date Issued .... •__ ___________ Application is hereby made to the San Joaquin Local Health District a permit to construct and install the work herein described. This application is made in compliance with County Ordinanc o. . JOB ADDRESSXLLOCA ION ----- ----,��-- -- ---- -- -- Owner's Name--- ---- ...........�4-..-.----•- _------ Phone.._..................------------ Address----------------- -- - ------ � Contractors Name.......................•.---........ . ......... Pho e dCl. Installaflon will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court MOtel ❑ Other ❑ Number of living units: .4- Number of bedrooms -tom__. Number of baths __1"' Lot siz ._ ... ..... ....... . ...........--------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel C❑ Sandy Loam ❑ Clay Loam ❑; Clay ❑ Adobe M-14a-rdpan ❑ Q `. Previous Application Made: (if yes,dote__ I.&T.__.1 No ❑ New Construction: Yes ❑.. No HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well_S-V--____Distance from ou dation___./Q..._...Ml ter l............... .....I No. of comps.tmenfis_____ ________________Size s _ _._:.Liquid depth____�f ,�.-----Capacity.....is sap �ield: Distance from nearest well_________________Distance from foundation.______.___________.Distante to nearest lot line.____._,.__.Number of lines---_.-___•_________________________Length of each line....___._._____...._...._... Width of trench....._...._._...._._...:....._Type of filter material-----------------:-----Depth of filter material__:---:----------------T�tsl length--.__.._.__.-.-----------------•---..Oe e,N t: 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_._.___....._..._.____......_.._ Size: Diameter--------------------------------------De th---------- •---------._Lit uid Capacity ..gals. Privy: Distance from nearest well---------------------- - -----------t---------.-Distance from nearest building ___-_-•------_-_______--. ❑ Distance to nearest lot line-------- ---- ------------------- -------------- --- - ------- ---------- ----------- Remodeling and/or repairing (describe):_ .. - J .. -------------------------------------- ._ .... I hereby ce that I have prepared thi application and that the work will be done in accordance with San Joaquin County ordinances, St e l s, and%rule and regula t 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, building etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----------------- -- ------•---- DATE------- G REVIEWED BY------------------------------------ ----- ---- ----------------------- ---------------------..............----- DATE--------I---•----- -----•----------•---------•-•------------ BUILDING PERMIT ISSUED-----_-_---------------- -------_- __--•--- DATE...-------------•- -- -------------------------•----------------•-•- •- - -- - ----------------------------••-•-•--• Alterations and/or recommendations:----------------------- --_--__ ---- ____________ _ __ ______.__ _.._ t:___L��1t►� S.____________________ _ _ ___._ ____ ...(NCXG�YL_.Y'l�ffi '. .r[Le �.�_�--------------------- -------------------------------------_-----__.........._-------------- _-_-- _ -_____._._.__--__-_____.__________-_________..__________.____.______._____-__-_______.-...____•._--..-___--________.._____ FINAL INSPECTION - Date------ �d . /SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 AEV18Eb B-59 8M 5-61 ATLAS