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Y APPLICATION FOR SANITATION PERMIT Permit No. ----- 40�--�J (Complete in Duplicate) y,i t Date Issued ----- / 4 3 Lf Z- 0 V t E'd L.�1 n' �OQrD�a Applica{ion is hereby made to the San Joaquin Local Health District for a permit to coAtrAf''and install the work herein described. This application is made in compliance with County Ordinance;N 9. JOB ADDRESS A rC&TION-------- ---- ---- ---- -- ---- -------- -- ----------- ---------------•-- -- -------------------- - -- - -- Owner's Name. f - ------ Phone------------------------------------ C .' v -- --------------------------------------------•-------------------------------------------- Address------------ ------ Contractor's Name--------- - - --- Phone- -- ....Z -0,/.,e-- Installation will serve: Residence 2-"A-partment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ 1 . Lot sized X�3S Number of living units: /_-- Number of bedrooms --- Number of ba s -� l - Water Supply: Public system ❑ Community system E-l"Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes U?*40ON'c ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is:available within 200 feet.) /� ,, y Septic T nk: Distance from nearest well._-5�'---_Distance from foundation..�,O--.---_-_Material-f..�` •- [� No. of compartments- °z'-------- Size--- . �"• �'� ------Liquid depth------'�7--- --------Capacity- . Disposal ' Id: Distance from nearest well..-_5�-------Distance from foundation..._ ._.....Distance to nearest lot line-__----______ 1 Number of lines--------- ------- -- ------ ----Length of each lin e---•-�4 -----------------, Width of french...._.2 ---------------___-` Type of filter material- / 4_ '..-Depth of filter material_____--�V-_._____Total length-----7.�____________________________� See age t: Distance to nearest w/ell_�r _�_____._Disfance from u,da ion----- -�...D•sfance to nearest lot line-___ _�-. of pits.._--.-/.............Lining material l.�!! Diameter----- �._..____Depth_�-G----------- Number .___._____ Cesspool: Distance from nearest well-----------------Distance from foundation-----------.--------Lining material-----------------.------------._--_-. ❑ ' Size: Diameter--------------------------------------Depth------------------------------------------- --------Liquid Capacity__•-----------------------gals Q Privy: Distance from nearest well-------------------------- ----------------------Distance from nearest building----------------------------------------- I& ❑ Distance to nearest lot line----------------------- ------------ ---------------------------- Ic Remodeling and/or repairing (describe):--------- ------------ ------------>. --------------- -------•-----...---•-----------------••-•---------------------•-•--------•-•--------------------- ------------------------------------ -------------------------------------- ------------------------------ -------------- ----------------------------------------------------1 •----------------•-----------------•-•----•------------------------------------------------- I hereby certify tha�-I- ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances to laws, nd r es and regulations of the San ,Joaquin Local Heal# District. (Signed)_ % I _. .. ._(O Ir and/or Contractor) � ��J ----- --- - --------------------------- ' ------ (Ti#le) - - - (Plot plan, showing size o ----- 4)ot, 9ocation ---of system in relatia r#o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------ - ---- ----- ------ -------------- -- ----•------------------------ DATE x --------------------- ----•----------- REVIEWEDBY-------------------------------- ---- --------------------------- --------- DATE -----------------------•------------------- BUILDING PERMIT ISSUED----------------------------------- ------ DATE-----_------ J --------------------------------- -------------- ---- -------------------- Alterations and/or recommendations-- ------------------ ------------ ----------------------------------------------------•-----------------•- .. ------------------------- --------- ------------------------- FINAL INSPECTION BY:--- --------------------------------------- --------------------------------D--aI-t--e--.-.-. --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814-North "C' Street 1 Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATw000 18-s4 - J