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APPLICATION FOR SANITATION PERMIT Permit No. -_'1,7--- (Complete in Duplicate) Date Issued U '! ."".---.. .--_-"--- 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 Ordinance No. 54.9 s JOB ADDRESS AND LOCATION: AX t,4, 4. .6, -� -f- '-�---- -- - --�-- `- _ Owner's Name_ : r -�- �' �------------- - -- Phone Address------------ --- ------------.------- ------------- . ------------------------------------•---....----- Contractor's Named-:./ ---------------- ------------ '---------------------------------•------------- PhoneeO_4 ,�_';'4 Installation will serve: Residence [;I/Apartment ❑ Commercial Apartment Hou ❑ Trailer Court ❑ otei ,. Other rr�� ll �j } � , Number of living units: ""r�_ Number of beclrooms4�"." Number o baths -"/__ Lot size -------- sF�6�_-/� /�__�""""_"_•-"-"" Water Supply: Public system ❑ Community system ❑ Private Number Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pub] sewer is available within 200 feetr} . Septic 'ank: Distance from nearest well �Dista�'c frprR foundation- 11_-y---_- , a ial--- �/�� No. of`compartments--_--.--.4"- _,_"Size7K-;----c"- - Liquid c(epfhr=_""_- :' '"'' • Capacity yy� 4s 1- r. Dispos ield: Distance from nearest well"___ istance from foundationIV- is#ante to nearest I t line--"�---_-_- Number of lines------"-_"-- ='� - .i �` f " Length of each line"""-- ��-:-��_t�--.�---.W,dth of trench---------,-�----:------)�-�-- ' Type or filter materia .�r �epth of filter material---.--- _ _"-x_._Total length.-"""""-"- "0---.""" 'S.See a e`Pit: Distance f neares w I : ."."._"----------- D's'fance�fr "foundation _"_ "" ,isfance to nearest lot lin "._ .- vJ ------- -be #n------------- `�®�.A„` Number of pit�s� �_..__".""Lining mate ria -Diameter`�� .-� ��' p}' �"/ � Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------..-.------_--._---- ❑ Size: Diameter--- ----------------------------------Depth------- -------------------•--- ------------ -------Liquid Capacity---------------------•--_--gals. Privy: Distance from nearest well...........".-",---- ------------------------------Distance from nearest building-------------------.---"------------------ w ❑ Distance to nearest lot line------------------------ Remodelingand/or repairing (describe):-.------------ -------------------------------------•-------------------.....-------•-----------•---------------------------------=------- ... ---------------- -------------------------------------------------------- ---------------------------------------------------!----------------------------------------------------------------------------_--- -------------------------_----------------••------------------ I hereby certify fhaf I have prepared this ap�lication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. , "` --"_-."".""._(Owner and/or.Contracto (Signed)' - -------------------- By--------_ -• ------ -----�------=------------------------------------------------------------------------------------(Title)-------------------------------------------- - ----------------- (Plot plan, showing size of lot, locatid11--of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY , - L x APPLICATIONACCEPTED BY--- ---------- -------- ------------ --------------------------------------------------------/DATE-.-A----------------------- ---------------------- REVIEWEDBY------------------------------- - - DATE - - ------------•-------------•----•--------------- BUILDING PERMIT ISSUED------•---•� DATE -------------------------- Alterations and/or recommendations: ----- ------------•---••-------------------------------- " "" --••----•-•------------------------ ----------------------------------------------------•------------------- -•------------------ -----------------------------------------------------------------------------------------------------------------•-.------ -------I---------------------------------------------------------- •---------- -------------------------------------------------------------- ------••---•---------- ----------------------------.------------------------ ------------------------------------------ -------------------------------------- - ------- ------------------------------------ ------------------------------•----------------------------------------------••---•-- - -------------•------------------ --------------------------•-- ------------- FINAL INSPECTION 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 Es�9 145446 ATw000