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tAPPLICATION FOR SANITATION PERMIT Permit No.9-4.. ._> (Complete in Duplicate) / aQ i Date Issued .__.__--7-__•5.,3 Application is hereby made to the San Joaquin Local Health District for a permit to construct stall the work herein described. This application is made in compliance with County Ordinance No. JOB ADDRESS AND OC ATION-------— -- ----- ;r -------- --- ----•....... ----- ..... Owner's Name--------- RANIc------------ --------------------------- -------------------------------------- Phone..Q.!!'�--1_........ .. GP_ Address............................. ........ Contractor's Name- 7777N�� ----------- -- Phone---F� 07 Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .1----- Number of bedrooms .-VNumber of baths /----- Lot size --------------------------- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table#457ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, Hardpan ❑ Previous Application Made: Yes ❑ No)R� New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-_-_-___-._----._..Material--_--_.____----.-_._-_-------•_---._.---.__.___.. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-------------------------Capacity------------- ------ Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- „1� ❑ Number of lines------------------------- `-_Length of each line------------------------------Width of french---------------------......._-_--.- Type of filter material_-_ _______._.__ __-Depth of filter material_-_---________--------Total length-._-.-_-_--__-__--__-----_-.----.-___--_- Seepage Pit: Distance to nearest welt-./OoeO- _-__-_Distance rom foundation--- Distance to nearest lot line__s__-_-_--.- Number of pits_�Yie�.r_____Lining material... R�4t��._.Size: Diameter--3.3--------------Depth__--_--------_._-----.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---______________________-_._.-__ ❑ Size: Diameter-------------------------------------Depth--------------------------------------------------Liquid Capacity---------------- -----------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ EJDistance to nearest tot line--.---------------------------------------- -------•---•-----•----- ---------_---------------_---------------------------------------- Remodeling and/or repairing (describe):- - --------- -- -------- - --_----------------- - --- --- - - - ----------- --------- -- ----------------- ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I hoesa ared this applicatio and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r regulations of th San Joaquin Local Health District. (Signed)-------------------------------•---•. --- ---- --------- ---- ---------------------ion -----(Owner d/or ontractor) BY•--------------------------------- - --------------- --------- '�--------- - --- --------- ----------(Title)---- - ------ ------------- ----------------------- (Plot plan, showing size of loton of system in relation to w s, buildings, etc., can be pla reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- - --------------------------------------------------------- DATE--------------- REVIEWED BY --------------------------- --- DATE -I--------------------------------- BUILDING PERMIT ISSUED------------------------------------- ------------------------------------------------------------ DATE.----- ----------------------------------------------------- Alterations and/or recommendations---------------------------------------------- -----------------------------------------------------------------------------------•--------------------------•- ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------- -----------•------------------------------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------------------------------------------------------------------- ------ ------------------------------------------------------ ------------------------------------ FINAL INSPECTION BY:------.--v.-. j'!. - -- - ------------------ Date-------------------- _(�_ _'f 3 --- ------------------------------------ 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 0-52 Revised W-2100