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APPLICATION FOR SANITATION PERMIT Permit No. ------------ <br /> (Complete in Duplicate) Date Issued A'D 1 6-3 <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and insfali the work herein described. <br /> This <br /> application is made in compliance with (;ourLfy Ordinance <br /> JOB ADDRESS AND LOC 'ION----------- <br /> ----------e....... -------- ---—------ . ............. <br /> ........ ..... <br /> Owner's Name------------)- �-ITI-114;?------------ ---- ------------------------------------------------ Phone-9-_Z12".eo-------- <br /> Address----........ --------------- <br /> -------------------------------------------*---------------- <br /> Contractor's Name--•---- ld-�----------------- ---- --- -- - - --------t,�_ -- ----------------------------------------- Phone--- <br /> Installation will serve: Residence El Apartment House ❑ Commercial F] Trailer Court E] Motel F1 Other 194#* <br /> Number of living units: _Number of bedrooms Number of baths Lot size <br /> Wafer Supply: Public system [] Community system F1 Priva+eA Depth to Water Table �'ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel [-] Sandy Loam E] Clay Loam 1-1 Clay El Adobe Hardpan ❑ <br /> Previous Application Made: Yes E] No4 New Construction: Yes,E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> o <br /> Septic Tank: Distance from nearest well________________ Distanced from foundation________________ Material______._____._._________.._____.____.._______.._.No. of compartments------ ------------------Size---- ----------------------Liquid depth----------- --------------Capacity----------- ---- ------ <br /> Disposal Reid: Distance from nearest well...._______.__._ Is <br /> ---- Distance from founclaflon--------------------Distance to nearest lot line_________________ <br /> ❑ Number of lines----------------------- <br /> - -----------Length of each line-----------------------------Width of french r Zo <br /> Type of filter material------------------------Depth of filter material---------------------- I Total length__________--__________--______ <br /> Seepage Pit: Distance to nearest weff_/�_ --------7--Distance from unclation--- to nearest lot iine__5�------------- <br /> n I <br /> Number of pits� ---:Lini material_ ----- Size: Diameter . <br /> Cesspool: Distance from nearest weil-----------------Distance from foundation-------------------Lining material__.____________________________Size: Diameter--------------------- ----------------Dept h---------------------------------------------------Liquid Capacity------------------ ---------gals. <br /> P <br /> Privy: Distance from nearest well----------------0--------------------------------Distance from nearest building-----_._____________--_______-_ <br /> ------------------- <br /> El Distance to nearest lot line------------------------ . I — t <br /> ------------------- -------------------------------------------------------------------------- ----------------- - <br /> Remodeling and/or repairing (describe): ------ ------------- -------------- ------------------------ ---- - - --------------------------------- <br /> ---------------------------------------------------------- ---- ----- ---- ------------------ <br /> ---------------­-------------------------I-------------------------------------------------------------------------------- ------ -1 - ------- --- ----------------------------- <br /> &----------—------ -------- ------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby cenfify that I he e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. State laws, d les and-regula+l s of the San Joe uin Local Health District. <br /> (Signed).----. ----- ------- -- - ---------------- -- ---------- - --------- --- ---- w-ner_and Contractor) <br /> reverse <br /> S. <br /> By:----- ---------------- - - - - -- ---- --------------- - d-,,eC---------{Title�_ <br /> (Plot plan, <br /> s in size of lot, location of system in relation to Ifs, buildings, etc., can be plat on ree4e <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------ --- 1- -5w- --- ---------- DATE --- /_ <br /> -- - --------------- <br /> REVIEWED BY----------------------------------- -----=-----1--------------------------------_.—------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE <br /> -------------------------------- <br /> Alferafions and/or recornmenclaf ions:- ---------------------- ------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------:_....----------------------------- --------- ------------- ----------------------- ------------------------- -----------------------------­­----------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------ ---------------------------------------- <br /> ------------------------------------------------------------------------I-----------_------------------------------------------------------------------------------------------------ ------------ -------------------------- <br /> --------------------------- ------------------------------- ---------- ----------•--/I----- -- ------------------------------- ------------------- --------------------------- -------------------------- <br /> ---PINAL INSPECTION BY---------------- ---- D,t-------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 10-52 Revised W-2100 <br />