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APPLICATION FOR SANITATION PERMIT Permit No. .O. n (Complete in Duplicate) --f Date Issued ...�_ ._. �.__ Application 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 NQZW9. JOB ADDRESS AND CATION-- � X0461A G?''�, ....................................... Owner's Name........ � Phone_-•.1�'�I----------•- Address ---- nn Contractor's Name U 1__.. ! 1 A ! 1 4 { 52_ S f Phone._ •. Installation will serve: Residence ( ` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units;O)Ijfl• umber of bedrooms 1-.Number of baths a_____ Lot size ___ __. __C_ -------------_______Water Supply: Public system ;< Community system ❑ Private ❑ Depth to Water Table 4477 ft. Character of soil to a depth of 3 feet: Sand❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A Hardpan Previous Application Made: Yes ❑ No M, New Construction: Yes ❑ No Q ` TYPE OF INSTALLATION AND SPECIFICATIONS: "fit (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well Distance from foundation' ___.____ __.Material'................................................. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity -- -- ---- Disposal Field: Distance from nearest well _Distance from-foundation Distance to'nearest lot line y ❑ Number of lines-----------------------------------Length of each line---------------------------...Width of trench................................... Type of filter material-____________ _______Depth of filter material--------------------__Total length.............-_____- ______-_ ________ It Seepage Pit Distance to nearest well_/';1.0_rAA--_Distance from foundation ___ ............Distance to nearest (ot line s'f Number of pits--- - Lining material-----� Size: Diameter---- _u--.............Depth._.o:L"!•-- Cesspool: Distance from nearest well______________Distance from foundation--------------------Lining material.__ ---------.-_-____-_ ❑ Size: Die meter..............-- -------......-..Depth--..... -------- ------ - ------ -----.Liquid Capacity.......... gals. Privy: Distance from nearest well--------------------------------------_-- -__---Distance from nearest building--------_-----------.................... ❑ Distance to nearest lot line--- ---- -- - ----- ------ ---------------------------- ---•_ ----• ------•. ..................•---- --------- Remodeling and/or repairing (describe) �i__ o ` t !___ ------------- ------- --------- --------------------- -- ------------- -------- ------------ ------------------ ------- ------- ------- -------- -------- ------ -------- ----- ------------- -------- ----- --- - -------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County. ordinances, St�elaws-. and rules a r gulations of the San Joaquin Local Health District. __ cc (Signed) ! ---- 4�.d�-.S 1�'- . ------- --- . 'or nd/or Contractor) By:--------------------- - �- __'- -- - -•------- --------------- -------_rtle --------_-------------- la(Plot plan, showing size of lot, location of system in relati n to wells, buildings, etc., canbep 'd on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYW_ V - _____________ DATE REVIEWED BY--_ ---- ----- ----- BUILDING PERMIT ISSUED---- -------- ------ ---- ---- --------------------- --------- ------ DATE.............................- •- ---_..----------- Alterations and/or recommendations:------------ ---- --- ---------- -------- ---_--- ---------••-•-••-••--• •-_... ----- ............................................ - -- ------- -- ----------- ------- --------- ------ --------- ----- - --- -•------ f FINAL INSPECTION BY-------------------------------------i --- � Date-•----- -�`-`-�`'�- - ---•--•-- •----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North"C" Street Stockton, California Lodi,California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 4: