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APPLICATION FOR SANITATION PERMIT �ermi�tNo. .. .. ►'A ( (Complete in Duplicate) _ V 0 Date Issued t Application it hereby de 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 Ordinan e No. 5 9. JOB ADDRESS AID CATION ' ---------- �/ - -5 r CCS- P- x'.12... Owner's Name------- A-�----------------------- -------- Address ----------------------------------------------y-�- > ----Ic -_' �� Contractor's Name-----------------------------------11�_- �-� --------,?---G"'---------------------------------------------- Phone.....f-n.%-.6--49.7.--- Installation will serve: Residence l- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___/__ Number of bedrooms -___7Number of baths .__. Lot size .___w.D_'.__X=___l__ :_: __' -----_,- Water Supply: Public system JX,Community system ❑ Private ❑ Depth to Water Table -�6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No;E�, New Construction: Yes ❑ No ❑ � 0.- . TYPE OF INSTALLATION AND SPECIFICATIONS:55"T / o septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Tank Distance from nearest well_________________Distance from foundation--------------------Material___________--___._-___-----_______-___-._-----__. —av---9 No. of compartments------�------------- -----Size-------------------------------Liquid depth--------------- ----------Capacity----------- . osal d: Distance from nearest well, ©- __-.-Distance from foundation___-1--------Distance to nearest lot line_-_,%?. ..... ( Number of lines........L-- ----- -------Length of each line------ -----.Width of trench-------AF - -� A.- Type of filter mate ria ._/ A-----Depth of filter material__1_d'"__-__--..Total length.a.0............................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- I] Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Dept h_-__-__-----_..__-_._.______.__-- 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---------------------------------..___-- /- ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--'%�-- ----- --------- --- ----------------------------------------------------------------•--------------------------------------- -------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------- I hereby certif at ve prepared his applica 'on and that the work will be done in accordance with San Joaquin County ordinances, State Tlas,,and les and reg I tions of a San Joaquin Local Health District. (Signed)-------------•--- .---------- ---------- -------infjowells, -- --------------------- Contractor) By: ------ ------ -- --------- Title---- s4'- - -/e------------ y (Title) (Plot plan, showing size of lot, location of system in relat buildin , etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - ------------------------------------------------------•--------------------- DATE-- ------------ ---- ------------------ REVIEWEDBY------------------------------------ - -T----------------------------------------------------------------------------- DATE- ---- BUILDINGPERMIT ISSUED--------------------------------------------------------------•--------------------------------------- DATE---------0-----------------------•------------------------ Alterationsand/or recommendations------------------------------------------------ ------------------------------------------------------------------------------------------•-----••--------•---- ------------------------------------------------------------------------------•----------------------------- -----------------------------------------------------•----------------------------••----------------------------- ------------------------------- -----------------------------------------------------------------------•-------- ------------------------------------------------------------------•••---•-•---•-------•--- -----•-•------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ---------------------- ------- -------•-------- •--•-- ------ - ---- ------------ ------------------ ............... 1-77 FINAL INSPECTION BY:. - DateI--- ------------------------------ 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