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APPLICATION FOR SANITATION PERMIT Permit No. 1___.___l-_--__-_ (Complete in Duplicate) /l1 40— Date Issued ----- ___1__-z_ Applica4ion is hereby made to the San Joaquin Local Health District for.a permit to construct and install the work herei described. ' This application is made in compliance with County Ordinance No. i / "(/ x JOB ADDRESS AND LOC ION.------ -0r-_ �-®--- --- -- ---------------------------------------------------- ---------------------------- ----- Owner's Name. ,... -¢- � ------------ Phoneme '' ' Address ------------ ------ Contractors Name-------------------------------------------- / ---------------------------- Phone Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1------ Number of bedrooms ...Number of baths -1..... Lot size ----.SV_x----I 0.0----------------_-.----_ Water Supply: Public system [R--Commuriity system ❑ Private ❑ Depth to Water Table 315rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes ❑ No� I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer'is available within 200 feet.)" Septic Tank- �G Distance from nearest well----------------------Distance from foundation------------------_Materiai----.-_.---..-------------------_-----------_---. ❑EX►5 No. of compartments------------ -------------Size-----------------------..-------Liquid depth--------------------------Capacity..--------------------- Disposal Field: Distance from nearest well------_._._ Distance from foundation---_-_.............Distance to nearest lot line--------.._----_. ❑ Number:of lines-----------------------------------Length of each line----------------------------_Width of trench---------------------------------._ Type o' filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage �__...._---Distan to nearest lot line______ Seepage Pit: Distance to nearest well___! _11 _Qisfiance om fo,ndation___'__ �� ( , j Number of pits_ - 9).Lining material ,P_ Size: Diameter....Zv3.......... Depth--.E.,�/-- ------------------ "V 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-------------.-----------------------.---. h6 Distanceto nearest lot'line-------------------------------------- ------------------------------------------------------------ •----•--•----- -------•----------------- 'r Remodeling and/or repairing (describe):_------ ` �----- lCounty ----------------- - - --•----------------- --------------- -- -----------------------------------•-------------------.------•-------------•----------•--------------••-•---------------••----•-•-----------•-------•---------------------------------------- ------ ------- "s•-------------------------------------------------------------•--------------------------------•--------•------------------------:-•---------------------------- ---------------..----- --------.I hereby certify that I he p pared this application and that the work will be done in accordance with San nty ordinances, State laws, and les d regulations f the San Joaquin Local Health District. -- --.- ---- '"� ----- --------- Owner and/or Contractor (Signed)-------•------------------------- ---- - - - 9 ( / ) BY= .'A * ' - --- (Title) 1 l (plot plan, showing size of lot, location of system in relation to wets, buildings, etc., can be plat on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_... ......... .. . -------------------------------------------- DATE_�---- -------------------------------------------- REVIEWED BY------------------------------- ------ -----------------------------------------------=-------------------------------- DATE---Z-----------•----•----------------------------------- BUILDING PERMIT ISSUED................ -------•-------------------------------------- -•--------------------------.. DATE--------�----------------=-------------------•----- Alterations and/or recommendations----------------------------------------------- ----------•------------------------•--------------•-------a .-..- ----------------- - - ----------------=----------- - - ------ - ----------------------------•----------------------- ----------- p ----------- 4 lL --- ---- 3 - " } 4-- -----�i� - --1-- -- ----- --- -- FINAL INSPECTION BY:. y ----------- ----- Date ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES9--2M ,ASAd6 ATWfI�� 12 54