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APPLICATION FOR SANITATION PERMIT Permit No. .- •_lzl'.. (Complete in Duplicate) / Date Issued ._MSA a�_ Applicaa-ion 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 in compliance h Coun Irdinanc No. 54 JOB ADDRESS A LOCATION..__ ---- Owner's Name--- --t --- -== - ------Aen --- ----------•-- •--- - -----•------------------- ---------------------------- Phone-----•------------------------------ Address... Z--- -----Tn-------�-- ----- - ------------R--------------------------------•-----------------•••- ----------------••---------------------------- Contractor's Name--- --' •----- -- ------ - ------ ----------------------------- -• _x_---2-•-r_--- phone_ " � � Installation will serve: ResidertVQh=Wpartment House ❑ Commercial [ iter Court ❑ -Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms -/--. Number of baths __ ___ Lot size --._ 40..- ;- ---2-0-------------------- Water Supply: Public system .Community system ❑ Private ❑ Depth to Water Table 3t. E Character of soil to a depth of 3 feet: Sand [Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[ Hardpan ❑ p Previous Application Made: Yes ❑ No A--.New Construction: Yes ❑ No [ — TYPE OF INSTALLATION AND SPECIFICATIONS: -(No septic tank or cesspool permitted if public sewer is available within 200 feet.)- Sept ��Fid: Distance from nearest well__ ______________Distance from foundation___________._.Material_._______.__.______.__.___•-__.__________.__. No. of compartments---------------------------Size--------------------------------Liquid depth___----------_--------Capacity----------------------- d: Distance from nearest well....__. _. Distance from foundation________________ ___Distance to nearest lot line________________.Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of fifter material_________________________Depth of filter material L._..___.--------------Total length------------------------------------------ Seepage Pit: Distance to nearest well-._-Distance om fo da`tion------- --------Distance to nearest lot line_. L- Number of pits-------I__.____---- Lining material__ Size: Diameter.____�_r____.Depth-----&V''-X;�'___ Cesspool: Distance from nearest well-----------------Distance"from foundation----------------- - Lining material----------------------._____-______ [� Size: Diameter------------------ ------ ---------- DeptH_. _r -----------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well--------------.-------------------------------..-Distance from nearest building------------------------------------------ ElDistance to nearest lot fine--------- ---------------------- ------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)---------- ------- ------------------------------------------•---------------------------------•--•---------------------------•------------------------ t ---------------------- ----------- ------ -----------------------------------------------------I------------------------------------------- •------------------------------------------- ------- -- -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances ate I ws, and s and gulations of flie San Joaquin Local Health District. (Signed)-_.- -- ••-- ----------- -------==------ ----- --- ------ (�ww r Contractor --- -- -- ---- y (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--------------:-- .-A6 ---------------- REVIEWED BY----------------- - ------ ------- --• ------------------------------- ---------------------------------------- DATE------------------------------------•-•-------------------- BUILDINGPERMIT ISSUED---------------------------------------- ------------------------------------ ------------------------ DATE--------------------•------------------------------------ Alterationsand/or recommendations:--------------------- --------- ------------- --------•-••--------------------------------••--------------------------------------------------------..------- 1--1----------•-------------•----------- --------------------------------•-------------- ------------------------------......-------------------------------------- ----------------•--------------------------------------- ------------------------------------------------ -------------------------------------------- ---------------------------------------------------- --------- --------------------- -- ------------------------------------- -----------I---------------------------------- -----------------------I-------I— ----------------------- -7-,/ FINAL INSPECTION BY:- ----------------- Date.- - - ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWnnD 12-54