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fk� ° APPLICATION FOR SANITATION PERMIT Permit No. �� (Complete in Duplicate) �--� 1 I "i ��` G Application is hereby ldmade to th an JoaquinDate Issued .! _ --53 This application is made in compliance w' o tcal Health District for a permit to constructwith ad install the work herein described. JOB ADDRESS AND LOCATION___._._____ Owner's Name------- _ __ ----- � - ---------Address ---------- --• - i -----o- - ------------------- ---- -------------------- Phone---- -- ' --------- --------------- -- --------------- ontractor's Name----------------- ----------- Installation will serve: Residence' -- ---- ---'------------------- Phone-- Apartment House -'--`---- ----------------- Number of living units: ❑ Comm ❑ Trailer Court ❑ Motel Number of bedrooms�_-- Number of baths ❑ Other ❑ Water Supply: Publics stem --- Lot size Y ❑ Community system / .-----" Character of soil to a depth of 3 feet: Sand ❑ Privat;yL, Depth to Water Tablet (Jff. Previous Application Made: Yes ❑ Gravel ❑ Sanam ❑ Clay Loam / ❑ No� New Construction: Yes y ❑ Clay ❑ Adob� Hardpan [] TYPE OF INSTALLATION AND SPECIFICATIONS: �No ❑ (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tank: Distance from nearest we I � ) }af'+ No. of compartments_ � ---Distance from �oundat5on______ ._.MatV_��6a`pa6 I---Size. �------------------- ---Liquid depth .Disposal Field: Distance from nearest well__._______-"_"-"-Distance from foundation____________________Distance to near ❑ Number of lines___.________ 'Y -----------------.-Length of each lineest lot line____"__._____-_- Type of filter material-_-_-_____ Depth of filter material____________________o+idthle f trench--- --- -------- --- See a e Pit: I - - ----- p Distance to nearest well-,-,7/- . - . Distance f m,fo ation _ g -- Number of pits --------Lining material Q --•-_.Dist_Distance to nearest lot lin _ ._„�_�" Cess ool: Size: Diameter____ __ p Distance from nearest well-----------------Distance from foundation_________________Lin Depth__._._�j�� Size: Diameter Depth --------------------------------------------------- Ing material - Privy: Distance from nearest well__-__ --------------- -----------Liquid Capacity____.-___-_-_-_- t1► { ----------------------------------- gals. ❑ Distance to nearest lot line _ -----Distance from nearest building ------------------------------------------------- Remodeling and/or repairing (describe): !' - - - ------------------------------------------ ------•-------•--•--------------------------------------------- --------------•----------------------------- - -------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with ' ordinances, State la nd rule nd 5 gulation the San Joaquin Local Health District. . San Joaquin County I (Signed)- - - -- ..-C BY: - ----- (Owne and or Contractor) = --------------- - Plot plan, showing size f lot, location of system in relation to wells, buildings, etc., can( Title - - - ---- ------------ -- ------ �ae�d__onrey__._rse side F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- __ REVIEWED BY------------- --- .. DATE_ BUILDING PERMIT ISSUED---------------------------- -------------------------------------- DATE Alterations and/or recommendations:._____..__ ----------- ----------•--------------------------------------- DATE------------------------------------------------------.- -- ------ ---- -------- ---- ----- ----------------------------------- ----------- --------------- - --------- _ _ - ------ -- ----- FINAL INSPECTIONBY -X_- ` - -"" ----- ---• Date-- -------- 130 South American Street SAN JOAQUIN LOCAL HEALTH DISTRICT Stockton, California 300 West Oak Street 132 Sycamore Street Lodi, California Manteca, California 814 North "C" Street ES-9-2M 10-52 Revised W-2100 Tracy, California