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APPLICATION FOR SANITATION PERMIT Permit No. .... .CFrO._(.. .. (Complete in Duplicate) 4- t—:7 Application Date Issued �.�...+ 7�!�..i Application is hereby made to the San Joaquin Local Health Dist rict for a permit to construct and inFi fFe work herein described. This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AN LOCATION.. . - ► Owner's Name.-'. .----- -"--- '-' ---'- ------- r ------------------ -- Phone---- --- a� ^ -------`---�-- Address_.�r" ..- t-e---- . Contractor's Name..-------------- ------------------------------- --- ---------------------- ------------ ............... Phone_------------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms ._:3. Number of baths _1..._ Lot size _6.._0_.X-------1-1-0 Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe N' Hardpan ❑ Previous Application Made: Yes ❑ No )( New Construction: Yes A No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welL_.. Q.--Distan )f m foundati ..� _..__...Mat 'al .._ _.. t - - --------- No. of compartments.__�1CC.....-.._.Size__. ._ -�� i uld dap/th_.._...�'-f.c pe -/? 4-_._.. Disposal Field: Distance from nearest well --- Number Distance from fo d tion,.. .,r..-- 'st�a c�e to nearest lot I' e_. Number of lines------..... ........... . Length of each li - a{trench.... .. - Type of filter material. _ _ .. ..Depth of filter mat=pp----Total length--------- � Seepage Pit: Distance to nearest well___...___------__Distance from foundation....................Distance to nearest lot lin ❑ Number of pits-------------- -------Lining material-----------------------Size: Diameter----------------------Depth---___......._-..._--------. .40 Cesspool: Distance from nearest well-----------------Distance from foundation_.._-------------Lining material._.._ - 11Size: Diameter---------...-------....----�--.Depth-----------------------�--------�-�------Liquid Capacity-...-------------------'--ga� Privy: Distance from nearest well------....._................._...__..._..--..Distance from nearest building.._--__....--_...._.__........_.`.'.'. ❑ Distance to nearest lot line..--- ------------------------- Remodeling __ .Remodeling and/or repairing (describe):--- .V rJc -• (fix ------_ -- _ .---- 4 -� -- - - - -------- ---- --- - ' -- --- ::- ----------- -. I hereby certif the I haPprepared plica Ion and that the work will be d e in accordance ith S n Jo ounty ordinances, State s nd rules and s of the San Joaquin Local Health District. (Signed)_.. . . ........----------- ----- _.. -- ----------- ------------- -......(Owner and/or Contractor) By:----------------------------------------------_---- -------• ------- ----------------------------------------------------(Title)-------------------------- --- -------- ..... - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--- ------ - - - DATE 11 REVIEWED BY - - . DATE---- '- t� - - - - - - BUILDING PERMIT ISSUED -- - - - -- DATE - - -- - Alferetions and/or rec mendatjons-------- ------ - -r...----- ----------------. ---- ..__. - ...�-�-,-�,r.--� �s-s.�� u_.�.v.u�.a,�r,r��::t.+; te.c.fr..�:�C'.��a....--�,.Ky - ------------------- ------------------------------------ ------------ ----------------------------------------------------------------------- --------------------------------------------------------------- -- ---- ------------- - ----------------I--------- ------- ------------------------ - - - - -- - - - FINAL INSPECTION BY:. ....- - .. Date.... f-e2 - ...__ ... ..... 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-9-2M 10-52 Revised W-2100