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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) f „. Date Issued ----� - . Application is hereby made fo'the San Joaquin Local Health Di tri f for a permit t construct an stall the work herein described. This application is made in. ompliance with County Ordinanc 5 JOB ADDRESS AND ATIONI_- -� Owner's Name ------ . ..... . -- ------------- - ------ - Phone Address---------------------- " - ---------- -•----------------------------- Contractor's Name_ -------------------------- 4 �L(,��' en - ---------------------House ❑ Commercial---•-- _ Phone.. Installation will serve: Residence � Apartmt H ----- --- -- ' ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----f-- Number of bedrooms _7�Number of baths .'�---_ Lot size ----- '� r r J �� Q---=--------------------- Water Supply: public's tem Community system.❑ Private ❑ Depth to Water Table ft. 4— Character of soil to a depth of 3 fee' Sand Gravel ❑ Sandy Loam ❑ Clay oam [] Clay y ❑ Adobe�rdpan ❑ Previous Application Mader Yes ❑ ;No New Construction, Yes ❑ No ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: o septic fank`or cesspool pe�mitfed if public sewer is available within 200 feet.) p is Tan � _ - . , _ +stance from nearest well-----------------Distance from foundation-------------------.Material_--_--._-_.-_---___ No. of compartments-------- ----- Size ---•------------------ D+ Osa l - ---Liquid depth---------------- -------- Capacity------ ---------------- s Distance from nearest well-----------------Distance from foundation.---__------.._-- Number of lines--_I------------------------- -Distance to nearest lot line--------___--.--- -----Length of each .line------------------------------Width of french-------- Type of filter. material---------- ------ _:Depth of filter material---___ See a e ..,nc.e -.-� _ .a Total length ----- ----- --------------------- p Distance to neares well Da :�-___Disfance om f nclation--- Number of -----------------Lining material--- .. 1� '--- �rto ne rest o JK .Dist a I t � YSize: Diameter---- _ Cesspool: t Depth- Z - -- , P Distance from nearest welly------------- •� ---�--� "--- 1 . --_Distance from foundation------------------- Lining material-----.---_---,_------- ❑ Size: Diameter ----------_...Depth--- 1 ------ -----Liquid Capacity -------- Privy: Distance from nearest well I p �'-- - -------gals. --------------- - - --Distance from nearest building ❑ 'Distance to nearest lot line..........-_--------------- ------------------------------------------------------- Remodeling and/or repairing (describe)--------------------- •- = •----- -- a -------------- ------------------------------------------- __-_-----__•--•------------------------------------- ------------ --------------------------`------ ---------------------------------------------------------------------------------------------------------------- - -.---_•---------- ------------` ---------------- ---------- --------------___-----•--------•____-_---_•._----_--_-_-•----.__-••---.-_•_- -_.--------------------__-------_----------.--_-----.- .---.._.._ I hereby cerfify at I have repar`ed his application and thaf the work will-be done in accordance with San Joaquin County ordinances, State la and rul and peg ations of San Joaquin Local Health District. - i . F (Signed)----------------•- �'f --...-�+ .--------- gY: — ----------------------------------------- {Title) ' ct 'T on}ra or) (Plot plan, showing size.of lot; location of system in relation to s, buildin s, ----- ---------------- g fc.,-can a placed on reverse side). - Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- DATEBY_-.---- � //-- --- -------- --------------------------------------:. ------- _ --------- BUILDING PERMIT ISSUED---:------•---------- dDATE_------ --/--- r ------ DATE-------.------ --- Alterations and/or recommendafions:---- -_--_- ----------------------------------------------------------- ------•-------------- --•---------- ---•---••--•--- -------- -- -------------------------------------------------------------------------------------------------- ----------- ------- ----•---- ----------••-----•---•--- FINAL INSPECTION-BY:. --_. � D .�-r _ �. ate-------- --'t--- _ 3 �. .. ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street ' � e !, 132 Sycamore Street 814 North '"C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-R-21FA Revised W-2100