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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� Date Issued -�Ol/f , 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 i"n compliance with Counfy rdinance No. 49, l JOB ADDRESS'XNU L CATION__,C/ 9 �� ---- �-------- ---ill ---- -- - -- ----- Owner's Nam •" 4 --- Phone _ Address------ Y1� ------------- - J 4 ---------= t Contractor`s .NameA._-.,.----- � -----------•-----•-••-- ----------- = = Prone----- k Installation will serve: Residence ❑ Apartment House ❑ Commercials❑. Trailer 'Court E] Motel ❑ Ofi}i r f •: - �F J Number of living units: _: Number of bedrooms _ �. Nuniber:of baths ----_-__ Lot'size Water Supply: Public system ❑ Community system ❑ Private 9?-f-epfh to Wafer Table _ ft. Character of soil to a depth of 3 fee+: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe e-Varclpan ❑ Previous Application Made: Yes ❑ No [g —New Construction: Yes ❑ 0�itA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: .� ` No (No septic tank or'cesspool permitted if public seweris available within 200 feet.) a 1 - Septic�ank: Distance from nearest { wel-----__.______-_Dis#ante from foundation--------------------mafgt'ialf e___ --- -----------------� 1 J l2�' No. of compartments := Size ----------------------------Liquid depth--------------------------Capacity ---� •0 , _ ----------.:--------- Disposal Field: Distance from nearest well-/`Q_ Distance from foundatio�n�_-- N I rer of lines ` pebof`filter mater�l /�--_---- --- Length of each line_-----ZAPS_-----.Width cofttre ch nearest �t�j_��-.`:' I' T y / .. --Depth of filter material---, �-----------Total length.----/AV--------------------- Se epageeypif- Distance fo nearest well--1pW-��pistance fr fo ndation--_ � ,(4 Number of pits..-_---_ -- � -----Distance to nearest lot line, - ----___Linin material._. _ .�fs/ -_Size: Diameter___-,e' --------------- w Lining �„� - .Depth----- _��--------------- Cesspool: - -f-- _ Distance from nearest well-_________.-"___Distance from foundation__--_._�_ --------Lining materral-:---_--"_--_-.__--"- ""_---_ Size: Diameter--•--------------- -------------------Depth----------------------------- -----------------------Liquid Capacity--- ----------------------- Privy" Distance from nearest well---" ---------------------------------------------Distance from nearest building �. ❑ Distance to nearest lot line_______- - - ------- ---- -- �s _ ; '�`"R modeli and/or re irin {describe:_-_P-__-,--�G�_ u �. ----- - -------- --- - ----------------------------------------------- __: 1_-__-__ ' t - --___.---"-.----------------------_______________________ � _______________________________________________------------------- �--__---- _ --------- e -------------- "-"-------------"'---------"-----•-------"""-----'"'""""-------•------------•'"------------------""""--------------------•------------""-----------------•--"•""""---.------.-__------------------ , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------------- �� ., ----- -- - � --- --------------------------------------------------------- ' By--------------------- ------------------------ r Contr ' + �Ti+le actor .CLW---------------------- (Piot plan, showing size of lot, Iota ' of system in relation to wells buildings, etc., can`be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY________________ ---- - ---------------------------------------- ------ DATE------------ REVIEWED BY ------------------------------ ---- l --- -- ------------------------ ---------------------------- ------ DATE--------T�---&AK------ BUILDING PERMIT ISSUED----------------------- ------------------- ------- ----------------------------------- Alterations and/or recom endations:-------------------------- DATE - --- ---•-----•------------•--------- -- -•----------------- ----- - --t-T------�=. ---------- •-- ---------- ---- - --- --------------------•----------------- -- ------ - --- ---- ------ ------ FINAL INSPECTIO f Date -------------------------------------- / - 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---4-2M , Ravisea 1-57 F.1'.to.