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APPLICATION FOR SANITATION PERMIT Permit No. [Complete in Duplicate] ; // ed _____�J�_. Applica{ion is hereby made to the San Joaquin Local Health District for a permito con tract and instal4 the work herein described. This application is made in compliance with County Ordinance NW4? JOB ADDRESS AND LOCATION -- s --- Name., 4= f --•-------------------------------- --- ------ ------- Owner'sPhone . ' --= r .. !- - ---- --- -•--- ------------------------ -------------•- f�_�r___�.�-.�------t•---- ------------�---------------------------------- Phone '!2__�__�_J I Contractor's Name..._.._...lC"r---�------�� {1 --- Installation will serve: Residence V' Aparfmmeent House ❑ Commercial ❑ Trailer 41 Court Mote! Other / 1. i r Number of living units: - �:- Number of bedrooms --/-. Number of baths -L____ Lot size------------------- - 3 K I S _ ft. Water Supply: Public system Communifytsystem El , Private ❑ Depth to Water Table;. Character of soil to a depth of 3 feet: Sand ❑ Glave] ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe)R]r Hardpan I❑ Previous Application Made: Yes No � ew ']Cons#ruction: Yes�❑ No�� ,r TYPE OF INSTALLATION AND SPECIFICATIONS:, " .,, {No septic tank or cesspool permitted if public sewer isI-availa6le.within 200 feet. p s - - t ; - 1 - d depth ' --------------------Ca aci ------------ p P ! _.___Liquid e No. of comprtments- Size q P. p tY ----- t e from foundation___-__ Material__..____._.._ 11 R ! Septic Tank: Distance from nearest well__.______ - Distance -- 'D' os I field: Distance from, ,nearest ell... Dista e from-foundation ._____._.Distance to nearest lot line.__----_-=C.__. p Number of li es--------- �----------------I------Lengfh of each line---------------------- -----.Width of trench P r w]ll_1 :_"" Distance f om foundation___f� ___--_.Distance to nearest lot line`------: Type or filter.material�---.___-_--- i_._.__be th of_filter material----------------------Total length__.._...._______..________ Seepage Pit: Distance to nearest a ' ., t a h - Diameter _ _ Number of pyla---- ---------- -----Linin t�atetI , rom f unda onL � g materialDptly---- -'---------- g w. , Cesspool: Distance f-orn nearest well_--____-.-_--.__Dis, ' Size: Diameter------------ --- ; Depth`` ,- i`' _= Liquid Capacity gals. ri y t Privy: Distance from nearest]well-----------------------------------------------77� Distance from nearest building------------------------------------1 ' - �_-:-----�---------- -•--- ---:-------;---------=--------- ------------------------ F9 xi Distance to nearesf'lo} line.. -...--- �---•--------•--•------------••�---`----------------•----------•------------•-•------:�1 Remodeling and/or repairing (describe--------------- ------.----- -._-- . I ---ASE--- -- f� --- -----------1------ -----------------•---- --� ---------------------------------------------- I -I == ----------- ---------- -------•- f --•--------- -------------------'----'--------------------'------"t----- i I hereby certify that I have Oreparedithis application-and-that fhe-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 Contractor) (Signed)--- -•--- ------------------- ------l------------------�- .. __� --------------------------------- By: {--------- --- ----,----= --- �-----]tor] -------------------------- /p Title_ r By:--•-------------- -- -------L �` I------`-------------------------------------- --(Title)-- (Plot ) Plot plan, showing sie of lot, location of system ' relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - I J APPLICATION ACCEPTED BY----------- r J DATE-----------•---- ' ------ REVIEWED BY-------------------------------------- _.. DATE �� s BUILDINGPERMIT ISSUED------------• ---- ------------------------------ DATE.-----*---•-----------------------••-------------„------ Alterations and/or recommendations:---------- ----------------------------------------------•---------- ....... 1 - - i , O- ----- --------------------------------------- -------------------------•---------- ----------- -------------- -------------- -------------------------- ----- FINAL INSPECTION BY:.. 1� - Date......-'----- 1---7- -S"j-------------------------------------- �AN 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 � w. IES-9-2M 145446 ATWOOO 12-54 1 --