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j APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issued �, �"__ Application is hereby made to the San Joaquin Local Health District for a'permit to construct and install the wo k herein described. This applic tion is made in compliance with County Or anc No. 5 9. JOB ADDRESS AN LOCATION_�Gr. Vit.:. �cl 71 U Owners - ;--:r -- -- ------------ . •---_-_- -- -- --- E - ------------------ i h Address----�_ Contractors Name----I-------- - --------------------------------------------- Ph will serve: Residence �t�Apartment House ❑ Commercial ❑ Trailer,!Court ❑ Motel ❑ Other ❑ Number of livingunits1.: _ _._ Number of bedrooms , _. Number of baths _�_- Lot size --_- 1_ T ---------------- Wafer Supply: Publics stem -rr y ❑ Community system R.-9 epth`to'Water Table Dft. ; Character of soil to a depth of 3 feet: Sand P-`G"ravel Sandy Loam ❑ ClaY Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes No PP ❑ PD-INew Construction: Yes ❑ No Pg— PHA/VA: Yes ❑ No [aY� TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if publics' ewer is available within 200 feet.} _. - . 5e�tic Distance from nearest well�dd e Distance from`fou p �, ndation---.f :----_.Mat Pial__ --___- No. of cbm artments__1. ---= �j p Size__. `------ -.Liquid depth' -- Capacity-2-d_4 Disposal Field: Distance from nearesf,well4__------- .Distance from foundation---2?�O _ Distance to nearest lot line--/ ---- Number of lines___ t UZr' __-Length of.each line___7 _'-V4; Widfh of trench__ -_--- _ - -----. Type of filter material YPO_C _Depth of filter material___/ --- --!.-Total length_.__/,,l.4--____� Seepage Pit; Distance to nearest.well---------__' ^� - ' Distance from _____________Distance to nearestlot line----.•..__,_.___ ❑ Number of pits------ --_- Lining material----------- -------Size: Diameter_-- Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation_--_.____--___ -.Lining material______._____-___:-____, ❑ Size: Diameter ------------- ----- L De fh------------•:------------------------ k _ r p. - Liquid Capacity--------------- gals. Privy: Distance from nearest well __-_#" -r_______ __________________ ^_Distance from nearest building i " g--------- --- -------------------------- 7--------------------------------------Dis#once to nearest lot fine --:: ^�-•••y- 3_-- - •----- Remodelin and/or repairing (describe :c a-_ " , _ }. ------------------------�^-••� is , -- -- - ------------------ -------- w .._ hereby certify that I have prepared chis a lien = - pp Pion,and that the work will'be done`in—accordance with San:Joaquin County ordinances, State laws, and•rules and'reguiatons of the- an"Joaquin�Local Health District. . +3 . (Signed)--------------- ---------------- --------------------------------------------- i Owner and/or Contractor) . ` . { 13y:.- / { -' -- -- (Title)__ (Plot plan, showing size of lot, locafion of syste` n relation to wells, buildings, etc:, can be placed on reverse side). .d. . ,FOR DEPARTMENT•USE ONLY— APPLICATION ACCEPTED BY____ ______ DATE_--� - .Y.. . REVIEWED BY ------ . ------ . �"�" 1! ------ ------------- ----------------------------------- DATE �� BUILDING PERMIT ISSUED_. ---------------- DATE t ations' + . i Alterations and/or recommend---•-------------------------------- --- -------------------------------•-•------------------ 4 } _______________ FINAL• ._ ----------------------- ....,f - _ Date = - SAN JOAQUIN LOCAL HEALTH DISTRICT ti ' _-_A .. —• 'l 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F.P.CO. �'