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7APPLIRCATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ZAT jisA This is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T application is made in compliance with County Ordinance No. 54 - ------------------------------------------------------------------------- JOB ADDRESS AND LOCATION---------3.4 J -- - -- --------- - ----- --- -- - , -- Owner's Name---- ---------- ------ ------------------------------------ ------------------------------------------ Phone----------------------------------- Address---------------7G - -- ------------;� ------------------------------------ ------------------------------------------------------------------ Contractor's Name----- A617-_ _ ---- ------4 -—-------------------------------------------------------- P h o n e6------ Q Installation will serve: Residence A Apartment House E] Commercial F] Trailer Court 0 Motel 0 Other Ej Number of living units: J_-- Number of bedrooms 4k--- Number of baths Lot size X---I ----------------------------- Water Supply: Public system � Community system [] Private E] Depth'to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel Ej Sandy Loam El Clay Loam F-1 Clay [_1 Adobe Hardpan E] Previous Application Made: Yes E] No Ej New Construction: Yes [:] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept' Tank:/ Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------- 1anK*1A,.j No. of compartments--------------------------Size---------------------------------Liquid depth------------------------- Capacity------------------------ Dis asal-Fiele-I.- r Distance from nearest well.................Distance from foundation__--;---------.--.Distance to nearest lot line--------__--_--.- Number ine----------------- Number c'f lines---------------- ------------------Length of each line-------------------------------Width of french------------------------------------ Type of filter material------------------- Depth of filter material----------- =---.-Total length-------------------------------------- J Seepage Pit: Distance to nearest well-------------------------Distance from foundation------1_4..........Disfapp to nearest lot line— �—)- ------------ Number of pits--=------I-----------Lining maferial___Z; G Diameter----- -1--------- --Depth----- '�L2-�-------------------- oc(- &-,-, ^5- Cesspool: Distance from nearest wO----------------:Distance from foundation-------------------.'.Lining material_------ ---------------------------- Q_ Size:,Dia metert—, Dept 4--�Liqtiid C-apacity-_—_= r Privy: Distance from rearest weli:------------------------------------------------0isfance from Aearesf building_--------------------------------------- ElDisfanc'e to nearest lot line- ---------------------------------------------------------------------------------- ---------------------------------•-------------------- Remodeling -- ----------------------- Remodeling and/or repai (describel:----------x------------------------------------------------------------------------------ ---------------------------------------------------------------- ------------------------------------- ------------& ---------- - ------- --- -- --------I------------------- ---------**------------------------------- IS - ------------------------------------------ ------------------- ------------ ------ �_6-------- 0-41- --- ------------------------------------------------------------------------------------------------- ------- ----- ----- ------------------------------ ------------------------------------------ --------------- I hereby certify that I have prepared thits appllcation�and that the work will be done' in accordance with San Joaquin Coun ordinances� State laws and les and regulations of the San Joaquin Local Health District. a (Signed)--------0-A-J-------- -------- ------ -------------------------------------------------------------jOwner and Contractor) -------------------------------------------------(Title)-------- ------------------------ (Plot plan sowing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION-ACCEPTED BY--------- -------------------------------------- DATE--- ---------------------------- REVIEWED BY--------`------------------------------- --- ---------------------------------------------------------------- DATE --------------- BUILDING PERMIT ISSUED---------_-------------------- ---------------------------------------------------------- DATE----- ------1i—------------------------ ------------ /---------------------- Alterations and/or recommendations: - ----------------------- -- ----------------------------------------------- -------------------------------------------------- -------------------- ------------------------------------------- ------------------ --------------- ---------------------------------------------------------------------------------I----------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- --------- -------------- -----------------------------------A--------------------------------------------- -------------------------------------------------------- ---------------------------------------------------------------- --------------- --------------------- FINAL INSPECTION BY:_ -------- ------------------------- 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-4-•-2M Revised W-2100