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I -.a �41 1 APPLICATION FOR SANITATION PERMIT Permit No�6_._�-l6--"_ 'in Du ' (Com pleteplicate) Date Issued Appl, ation is hereby made to the San Joaquin Local Health District for a permit to construct and insfall the work herein described. This application is made in compliance with County WOrdince No. 49.JOB ADDRESS AND OCATION_..__ _-_ / o [ G- ,• Owner's Name------- �_: ------ ------- -- Phone- - --=-•T--0------ . . ••------- . - --- I -----------------Name----- ....= �-f-y-- ---------�-t-''� � ��.: ------ Phone-- Ins}alfation will serve: Residence Elk-Apartment House ❑ Commercial ❑ Trailer Court [❑ Model Other ❑ Number of living units: _-_I___ Number of bedrooms __9- Number of baths ---.�_ Lot size ___�i� �_/o�(�--� LL'' Wafer Supply: Public-systern` Community system'❑ ' private ❑ Depth to Wafer Table .-7d ft. Character of toil to a depth of 3 feet: Sand ❑ Gravel E❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ PPrevious Application Made: Yes ❑ No ❑. New Construction: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: ll� r (No septic fank'or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well_____--__-�--_Distance from foundation____________________Material________ -________..________ No. of compartments - -- Size-_...�-'----------------- Liquid de th------------------------ Disposal Field: Distance from nearesfi well_':-- _- ,-_-Distance from foundation-_._______--.____.Distance to nearest lot line_______________ ',❑� Number of lines------------------------ Length of each-line------------ ----------------Width of trench.----------------------- --- Type or' filter material___'r--- ------------Depth of filter material-------- Total length_f..-------------------------- ------ --k Seeps ,'Pit: Distance to nearest vi Ir-001 --4y.-__Distance fro fou dation____r Q f-__..Dist n f� to nearest lot line__-----�-__ Number of its._-'___ _- p _Lining material- .Size: Diameter_______ Depth.__-_c? -�� f Cesspool: Distance from nearest=well-----------------Distance from foundation_-,-----------------Lining material__.___.__-----___.---_____-_._------- I ❑ Size: Dia meter----- ----------='----------------------Depth------------------------------------ ----------------Liquid Capacity----------------- gals. Privy: Distance from nearest well------------------------ - '_______________________bistance from nearest building ❑ Distance to nearest lot line----------------------------------------- - ------------------------ ----------------------------------------- Remodeling and/or repairing {describe_I_------------------------------------- ; - ---------------•-------------------------- ------------------------------------------ -------------------------- 4. --------------------------6--------------------------------- ------------------------ --------- ---------k7-------I----------------------------------------- ________________________________---_____________________________________________________________________________________________________________________________________________--__.____.-__-___________---__.__--.____ I hereby certify that I have prepared this application end We fhe work will be done in accordance wifh San Joaquin County ordinances, Staff laws, and I s and regulations of the an Joaquin Local Health District. �(f/1 1 (Signed) ----.. � -- 7 {� and/or Contractor)' (Plot Ian showing size of lot, f A --------------- {Ti}le) h .� " p g location of system in relation to wells, buildings, etc., can be placed.on reverse side). 1 k FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY_____________ ____ - -------------- -------- --------•------------- •-------------- - DATE-- ----I-A BY , . ---------------------- - DATE- ---------------------------------- BUILDING �, ... PERMIT ISSUED--------------- --------------'----------------------------------•-----------=----'--- DATE----------------•--------- Alterations and/or recammendationsi______ _------------------ --------------------------------------------------- ----------------------- ------------- -------- ------ -------•------•-------^- -- ? FINAL INSPECTION BY:- ----- Date------------------- --- ------ -- ----- - SAN JOAQUIN LOCAL HEALTH DISTRICT I f30 South American Street 300 West Oak Streetl 132 Sycamore Street 814 North "C" Street � Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-4-2M t0-52 Revised W-2100 !