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_ APPLICATION FOR SANITATION PERMIT Permit No. 4--F- 7-0-__--- 1 A 6 (Complete in Duplicate) Date IMc�-� ue �/c5_~� Application 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 County4,nance No. 9. �� ----•------------- ----------- JOB ADDRESS A LO I � 41 Owner's Name-- �it -----------------•--------- •----------------- ---------------------------------------- Phone--,-.---------- t�1'W3----- Address---------- ---- --•-- ----------------- - - -------------------------------------------•--- Contractor's Name------ ------------------ --•----------------=---------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot h❑ Other ❑ Number of living units: __ ___ of bedrooms _ Number aths ___[__. Lot size ___ _ 4VP 417 _A-6-6--------------------------- Number Water Supply: Public system ❑ Community system ❑ Private Mr Depth t Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam Clay Loam E] Clay ❑ Adobe C1 Hardpan El Previous Application Made: Yes Q No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publicsewer is available within 200 feet.) i Septic ank: Distance from nearest well_�__�_ Dista c4rom $oun ion___[9-------.Mat rill------------------------ -------- ____ No. of compartments_-._-_.___ __ _ t_Size ------ _xLiquid depth____ _____________Capacity__4_ __ Dispos Field: Distance from nearest weS — _-_.Distance from foundatio __ / .Distance to nearest lqt Ii ------------- r; Number of lines____________ _ _rte_�ngth of each line__�__q __ ______---Width of trench______��rr __ _ of filter mater; -'_ !' 9-,1.- g C ---------------- Type ----- h of filter material___._-__�- Total length __ ____ 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-------------------------------------- El Size: Diameter--•-----------------------------------Depth-------------------•--------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_---__-______________________________________Distance from nearest building__-__-____.-______________-___________-.. ❑ Distance to nearest lot I' --------- ------------- a / q &.A Re sling a /or rep ring I ribs}. y {'' r �r --- --------- .' --- -----•••------------•-----------•----------------------------------------------------------------------- -----------------------------------------------------••- �--------------------------- ---------------------••- --------------------------------------------------•--------------------------•----------------_.-• -------------------------- --- --- --- I hereby certify that I have pre ed this application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws, and rules a r gulations•of the San Joaquin Local Health District. ------ ----------- Owner and/or Contractor (Signed) N { } ------ Title ---------------------------------------------------------------- B • (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------- --------------------- DATE I-----------------------7------------------------- REVIEWEDBY-------------------------- - ---- - ------------------------------------------------------------------------------ DATE-------6---------------------------------------------- BUILDINGPERMIT ISSUED-------------- ----------------------------------------------------------------------------- DATE------ Alterations and/or recommendations------------------------------------- ---------- -----------------------------_---------- ----------------------------•-----------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------- --------------------------------- ----------------------- ------- ------------------------------------------------------------------------------------------------------------------------------------.--•------------------- ----------------------------------------------------------------- - - - -------------- ---- -------------------------------------------- - - -- ----- - -- --- ---- - - J� I FINAL INSPECTION BY---------------- /_.�-- O' ------ Date------------ k --------------•-------- , f - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M B-51 Revised W-2100