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APPLICATION FOR SANITATION PERMIT 4�'P/err�4' No. (Complete in Duplicate) Date Issued 1--clAX-1-1 VllApplicafion is hereby made to the San Joaquin Local Health District for a permit to construct and work herein described. This application is made in compliance with 1; my Ordinance No. 549. 4 yu or a permit to construct and 9. .. .......... -- - --- ---------r�- ---------------- ------------- .I.jbB ADDRESS AND 4LC TION.... ---------- ------ -- - --------- --- - --- ----- ............................. ... Phone------ Owner's Name---------- Address-----------------_--- v f - -------- Contractor's r -;5glvs - Phone-- T Installation will serve: Residence Apartment House 0 Commercial E] Trailer Court E] Motel E] Other E] Number of living units: _I_____ Number of bedrooms 1--lNumber of baths I--- Lot size ------------------ Wafer Supply: Public system 0 Community system -[-] Private E] Depth to Wafer Tablejj__ ft. Character of soil to a depth of 3 feet- Sand E] Gravel E] Sandy Loam E] Clay Loam [] Clay 0 Adobe E] Hardpan ❑ Previous Application Made: Yes E] No X New Construction: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ,8epfic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- R No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity---------------------- Q'isposal Field: Distance from nearest well--_--------------------------D;stance from foundation--------------------Distance to nearest lot line_____________-.-- 0 Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter material----_------------------Total length----------------------------------------•- SeeRpa e Pit: Distance to nearest w4---/VOIVE---Distancerorn foondat;on__,34? Distance to nearest lot line___----------- Number of pits-_07�___Lining material---15.jK1*,_Size: Diameter-- --------Depth_02-s---------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-------------------------------------- F Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-----------_---------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-__----_______________-__--___-_.--_. h} ❑ uilding------------------------------------------ 171 Distance to nearest lot line---------------------------------------------- - V Remodeling ine----------------------------------------------- Remodeling and/or repairing (describe):------ -- ------- --------- --------- ---------------- -------------------------------------------------............. ------- i--- ------- ---- -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ---------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counily ordinances, ate laws, and rules and1,A115�Uions of the San Joarqui �a�lalfh District. (Signed)--------- ---- --- ----l------------- --- 7---1I-R-1-514------- - -- ---- -- .2'*c_ ____(Ownec an /or Contracior) By:------------------- -----------(Title)-------- —------------- -- - -- ------------- V- ----------- S� (Plot plan, showing size I 10Z locationof system in relation to w Is, buildings, etc., can be placipon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�? -------------- DATE-C,:%—-------------------------------------------------- REVIEWED BY------------- ------------------------------------- ------------------------------ DATE__ ----------------- ------------------------------------------------------------------- — ------------------------------------------------ BUILDING PERMIT ISSUED--------------- -------------------------------------------------------------------------------------- DATE-------IY% AIterations and/or recommendaflons:------------------------ - -- -------------------------------------------------- ------------ -----------Z� -------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------- -- ---- - ---------------------------------------------- --------------------------------------------------------------- ------------------I--------------------- ---- --------------------------- --------------------------------------------------- - ---I------------------------------------------------------------------------------- --------- ---------------------------------------------------------------------------------- ------------------- ------------------------------------------- ----------- --- ------------------------------------------------- 0 —/ 6/ FINAL INSPECTION BY: — 4 �21 -- ----- 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-9-2M 8-51 Revised W-2100