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I APPLICATION FOR SANITATION PERMIT Permit No. v.�_.� ......... ( p plicate} "c^ Com lets in Du Date Issued/--.�__fZ_�s.__.___`� �( q Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ' This application is made in compliance with County Ordinance No. 141, - '�... JOB ADDRESS A`NDi ---OCATIOI�------------- , hhx'' _*_.._._ _ -- ------- - Owner's NameN 4��"� .'I_ -_ 1------ j11. _ ! =Address------------- ! ' -----•-•------------ ------- ------------ ---- I-------------------------------...... --- ---------------• ---•----------------------------------- Contractor's Name--- ---•-•--- -- ------ ------------------------ _ -----------------------------------------•- Phone Installation will serve: Resident [,Apartment House ❑+ Commercial ❑ Trailer E urt ff'-Motel- Q Other . r 4_. J i4 flr�-.�__ /O. g er of baths _-1---- Lot sae ---------------` Number of living units: __ ___ Number of bedroom-- Numb❑„ • Water Supply: Public system Community system Private l Depth to Water Table -------- ft. i i Character of soil to a Aepth of 3 feet: `Sand El ❑ Sandy Loam [] Clay Loam E] Clay ❑ Adobe r Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes V No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: i +� [No septic tank or cesspool permitted if public sewjr is available within 200 feet.]f� j Ma Se ti ank: Distance from nearest wel .______Dish. f Fn f dation___1_i -____ ate il__ '� '__________. ______ ________ p '� ------Li Liquid depth--------�----------._Capacity__�_o� No. of compartments_---- --- - 4____r.__Siz ____•- q f___ Disposal Field: Distance from neare3t'w. i# Distance from foundation -- ____.- Distance to nearest lot li '�'te•+'� d Number of lines--------- -- ---- ----•- g each line-------------- - ?¢----..Width of trench_----- t. _#------____-- __ Length of ea • Type of filter materie�_ `4�'C', Depth of filter material------_l.!�-----------Tot'l length___________/__-_ ------------------ Seepage ________________ p g Humber of its________________ Linin material_____ rn foundation--------------------Distance to nearest lot line_____________._. See a e Pit: Distance to nearest well______________ Number g Size: Diameter r"T -------.Depth---------------- Distance ro ❑ P Cesspool: Distance from nearest well_________________Distance fro foundation----_t___.'_______-Lining material___________________._____________.__. ❑ - Size:;Diameter-------------------------------- ----------------------------------------Liq'uid Capacity----------------------------gals . Privy: Distance from nearest well.----- Depth,__ _____ _IDistance from nearestibuildin ______________________ ---------------g----- ------------------ ❑ Distance-to nearest lot line-------------- ----------------------`------------------------••-----•---------- - =--------- ! �. Remodeling and/or repairing (describe):-----------------------=------------- ---- ---.......--------------------- ----------- ---------------------------------- ----------------------------------------------------------- - *I: -----••-------------------------- r �, - ----•---------------------•---------------------------•--------------------•-•-•-------- -------------•--------•---- " -------•------------------------•--------•-••---------------•-----1--1-------------------- ------------------- i t ordinances, State laws- and rules r pa d t dons li ati San Joaquin-- -- o will--------------------------- - • e in --ccor- I hereby certify that I have prepared this !'station and that the work will 6e done in accordance with San Joaquin County Local.Health District. �, f -----{Owner and/or Contractor) [Signed]------------------- --- -- - ---------- -------------------------�Ar-�-J�---" ---------------- ------�-------------- -- --------------=----- if By-------- - -----------------------•----------------y-------------------------- lbuildmgs, etc., -ca (be�place� [Plot plan., showing size of lotjocation of system in relation to wells, d on reverse side]. En FOR DEPARTMENt USE ONLY APPLICATION ACCEPTED BY-k-.-4_ _._._._ __.._ REVIEWED BY-------------------------------- ---�--------- ------------ --------------------.�--------------------...--------- DATE--��----...----------- --------------•------------------ - ------ DATE--- - --- - BUILDING PERMIT ISSUED---------- -------------------------------------------------------:L IJATE-----°--��------------- •-----•----------....------------ Alterations and/or recommendations------------------------------------- �~ - -------------------••------------------•--•--------•- ------------ i ----• •-------------------------------- -•-•------------------------------------------- ------------------------------------------'----------------------•------------- -•------ ---------•----•--------------------- •------------------- 1 ------ --•------- -- l s FINAL INSPECTION BY::--- /I/ ------------------ ------ Date_ -----1-------------------- - ---------------- -----------------•--- I SAN JOAQUIN LOCAL (HEALTH DISTRICT 130 South American Street 30D West Oak Street ', 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �I cc a—�r� Re"i,o W_9inn