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��•� ''�J APPLICATION FOR SANITATION PERT No. (Complete in Duplicate) V� ,� f Date Issued __ 121ST --- ------ - ----- 3 /c/ Application is hereby made to the San Joaquin Local Health Distric+for a permit to construct and install fhe•work herein described; This application is made in compliance with County Ordinar" N,o. 54 8 t } °� .. fvwlVQ 06- JOB ADDRESS AND L CATION-- - -- - -- - -- 7------ W Owner's Name----------- f!'Vz - -------------------- -- --------------------------- Phone------------------------------------ Address---------------- .....± _ _._ nn_ Contractor's Name . =� --------- ------•-- ..__ Phonefi/� --� - _ Installation will serve: Residence Z--A_"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/__ Number of bedrooms _ _ Number of baths / Lot size ....... ------ ----------- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table 15Z ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay_ Loam ❑ Clay ❑ Adobe 2?-'P"ardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes [ lo ElFHA/VA: Yes P- N o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: x +, (No septic tank or'cesspool permitted if�u�biic e r is available within 200 feet.) � + Septic T k: Distance from nearest welly- _Distance from foundation- --- el �-f �-- .i Material ��w ". , No. of compartments_____ _____________Size__ __,JL`,, -------Liquid depth-____"_�.A---_-__-_Capacity___ifff�__ Disposal e d:- Distance from nearest well./.mof_Distance from foundation—/0----_.-__-Distance to nearest lot line__________ _ Number of lines___________ •Length of each line-__4S----- -._.Width of french______R_,�__ , --- - .i � ------------------- Type of filter material___ Depth` of filter matenal____. __-___--Total length____ ,S`p_________________________ See pag Distance to nearest well__ IJA Distance-f rri f Tndatiom___/4_"__'___.Distance to nearest lot line_____S__----- Number of pits____ jZ-_-------Lining'material:_ Size: Diameter'.---2�_j--------Depth_____R-Q_l-_______________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining _ ❑ t r • material_-_ __-_.._.--_____________---___-__. Size: Diameter-----i--------------------------------De th- ----------------------- - ---------------Li Liquid Capacity - -------- gals. Privy: Distance from nearest well___________________________ -____.__--------Distance from nearest building_-------_________________ ❑ Distance to nearest lot line--------------------------------------------------------------------------------------•-- ---------------------------------------------------- Remodelingand/or repairing (describe):-----------------------------------------------------------------•---------------------------------------------------------------- ------ = -----•---•-------------------------------•------------ -----------------------------•-------------------------------- --------------------------------------------------------------------------------- ----------------------------------------------------------•---------------------------------••------------------------------------------------------------------- I hereby ify that I have prepared this application and that the work will be. done in accordance with San Joaquin County ordinances, S a laws and rul nd regulations of the Sa Joaquin Local Health bistrict. . ,. -- -- --- (Signed)------- ---- ---------- ------------------ - _- q � ------------------------------------------------==- - -- caner and/or Contractor) ---- --- - - 6 • -------- - - - L- ------------------------------------------------- (Piot plan, showing size of lot, location of sy in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ----------------------------------------------------•---------------------------- DATE- ;--------------------------------------------- ----------- REVIEWED BY---------------------------------- ------ - ---- - - -- -- ------------------------------------------ DATE_—----------------------------------------------------- BUILDING PERMIT ISSUED-------------- ------ DATE------0 fir------------------ Alterations and/or recommendations--------------------------------- - -------- -----•-------------------------------------------------- '----•-••---------•---------------• •- -------------------------------------------- ---- ------------------------ -------------------------------------•-•-•--------------•--------------- rl ------------------------ �� + k --------w---- ----- ► � s ` ----------------------- ----------------- ----•---------------------------------------------------------------------------------------------------------------------- --- ------------------------------------------------------------------------------- ------ FINAL INSPECTION BY:.____, _ ! 1 \ _ Date_ ___�__r ---------------------------------------------------•---- 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 Revised 1-571F-P.CO. r �