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-� APPLICATION FOR SANITATION PERMIT Permit No. y x•17 (Complete in Duplicate) ' { Date Issued Application is hereby made to the San Joaquia�,o�cal Health District for a permit to construct and install the work herein described. This application is made in compliance th Co { Ordi an ]tJo,� 549. JOB ADDRESS AND LOCATION-.-,------:--- - ----- --------�--�---- ------------------- ------------------------ --------••---------------------------------• -- ------ - - �_ Y Owner's Name----------------•------------ j/ ttr _.------- Phone.------ ....---- --------------_--_---------------------- --------------_�' �� " ------------------------------- Address - ----- Phone---7.77-- el� - •---------- Contractor's Name----------------- -�---- -`-'� ----------------------- Installation will serve: Residence jK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ G ° " ---°"--�---------------------- Number of living units: ___/_ Number of bedrooms _-- Number of baths ---/--- Lot size ------------------- , Water Supply: Public system,®. Community system ❑ Private ❑ Depth to Water Table -41-P ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,®. Hardpan ❑ Previous Application Made: Yes ❑ -No)� New Construction: Yes ❑ No ❑� � I)A- '�- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic Tank: Distance from nearest well-----------------Distance from foundation-_--_--_-_-__----.Material-----_------_---_-_----..---__-------_----_----. �` `L.�I No, of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Relc,: Distance from nearest well--_--------_—-Distance from foundation--------------------Distance to nearest lot line---------------.- Pj Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------------- length_---.-__---_____----------------.-._------ �, Seepage Pit: Distance to nearest well----"tgy 'Distance from foundation-.ar_Q._ '--_....Distance to nearest lot line--- 1 Number of pits--------- ----- -----Lining material�,N��.-_5----Size: Diameter._-_ .r 1 e-4 ;k Depth- .R-Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_----_------------_----.-_-__-_-____-.Q ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity._-__--------------.------gals Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------....-------_-___----------__-.--.-� ❑ Distance to nearest lot line---------------------- --------------------------------------------------------------------------------------------------•-------------------- fi Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------•--•-------------------------------------••--------------------•--------....-------------------------------------- ! hereby tify that I have prepared this application and that the work will be done in accordance with.San Joaquin County ordinances, S. ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-_-_-_-- _-:. r Contractor �.._ By:--------- -- ---(Title)---- - -�?r. xr`. ' (Plot plan, showing size of lot, location of sys m in relation to IIs, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------- ------------------- ------------------------------------------------------------ DATE------------------------------------------------------------ REVIEWEDBY---------------------------------------- -- - --------------- -------- --------------------------------- DATE------ BUILDING PERMIT ISSUED------------- - ----- ---------- - ------------------------------ -------------------- DATE----------------------------------------------------- - Alterationsand/or recommendations---------- --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------.------------------------------------------------------------ -------------------------------------------- ------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- FINALINSPECTION BY:_,----" -------------------------------------- Date----- ------------ `-�-------------- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Horth "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-Si Revised W-2100