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APPLICATION FOR SANITATION PERMIT Permit No. c D[/ (Complete in Duplicate) fj 3�S 7 � p Data Issued Applica+ion 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 in compliance with County Ordinanc No. 5 9- JOB ADDRESS AND LOCATION------------- ® -�j- --- -------- -- - Owner's Name----- ,/ ✓t' AVI VZ.' - -----=-------- --------=--------------------- --------------------------------------------- Phone--------------------•--•--------•--- Address------------.E_'_� f - *` -- ------ ----- ----------------•---•-------------------------:------- -------------•----•---------- Contractor's Name---- ---_-- �� f !' �" Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel-❑ Other E❑ Number of living units: _f.-- Number of bedrooms-___ Number of baths .,f___ Lot size ----------------------------- Water __________________________Water Supply: Public system ❑" Community system ❑ Private_�Dep+h to Water Table ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobalardpan ❑ Previous Application Made: Yes n No New Construction: Yes L6,'�o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if.pu6U.c sewer is available within 200 feet.) 1 fDistance from fou dation_.___ _______.Material___- _ _ Septic Tank: Distance from nearest weype :_ _No. of compartments_______ Size- ---• -_r'/---Liquid depth____ __:___..Capacity_____ ��- Disposai Field: Distance from nearesty+ell. _.47__...'_.Distance from foundafion.� _ _ _._______.Distance to nearest 1 li �f�___.__ f Number of lines..`-�----- - .________. _Length of each line.__ "�_______ ________Width of trench___._ ------ Type of filter material_ -Depth of filter material____ _ _____----- _Total length___.___________------------------- Seepage Pit: Distance to nearest well... ---------Distance fr m fou afion__ ____-_.Distance to nearest lot line________r_. Number of its--_________________Linin material, /��..Size: Cesspool: Distance from nearest well------------------Distance from foundation------------------- Lining material---------------------------:______.___. ❑ Size: Diameter--------- ---------Depth-----------------------------------------------------Liquid Capacity,, -------------------------gals. r Privy: Distance from nearest well-----------___.- i-1k'_.:.-----------------Distance from nearestbuilding,:___.___________-_____________-__._. ❑ --Distance to nearest lot lined_-:•_____"------------------------------- - .`--------------- ----------------Remodeling and/or repairing --- - --------------------------------------- ------------ --------------------------------------------- ----------------------- :�. -------------------------- --------------------------------------------------------------------------------------------------- ----------------------`----------------------------------•-----------------•---------------- 1 hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws; and rules and regulations of th San Joaquin La i Health District. �r __ sir-Gontractor (Signed)-------•--------- -- ...... --------- ...-- - ----- --------- ---------------- ----- ------(Title)_ Plot Ian, showing size of lot cation of system in relation to wells, buildings,-etc., can be laced on rev+ ( P 9 Y 9 , p er ide). -- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___- ----------------------- r DATE-- •-------------� ------ --------_------------ REVIEWED -- -- - REVIEWED BY-------------=----------------------------------------- ---------------------------------- -------- ---- DATE--=- -------- BUILDINGPERMIT ISSUED---------------------------------- ---------------------------------- -------------- DATE----------9------------------- Alterations and/or recommendations----------------------------------------------- =` = - -- --------- -r - — . -----------------------------------------------------------------------------------------------------------------------------------------------' ....................................------------------------- - �. ----------r ----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ----- ----------------------------------•------------------------------------ ----------------------------------------------------------- FINAL 4NSPECTION BY:--:--------- '-------------------------- Date--- ----------- = SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American•Street 300 West Oak Street 132 Sycamore Street a 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 4-57 F.P.CO. i�