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APPLICATION FOR SANITATION PERMIT a permit No.,.17 - �� (Complete in Duplicate) / . Date Issued i r 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 o.X.,?_ JOB ADDRESSA D LOCAT N.-• _ ------ =€ , ---------------------------------------------------------------•�'"�"� r . ---------•---- Owner's Nam -- --f--•- Addre '_.. =' Pon - 4 _...,= ----------------------------------------- ----------•-•--------- - Contractor's Name n = - --------------------- -- Phone.. `�/ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __- Number of bedrooms Z_._ Number of baths Lot size------ - -------------------------- Water Supply: Public system, Community system ❑ Private ❑ 'Depth to Water Table�4�7ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam L❑ Clay Loam ❑ Clay C] Adobe4 Hardpan ❑ Previous Application Made: Yes ❑ No� New Construction: Yes No ❑ •• a `` TYPE OF INSTALLATION AND SPECIFICATIONS:: + (No septic tank or cesspool permitted if public sewer is available within 200 feet.) " Septic Tank: Distance from nearest wel_ �_Distance from foundation___ r ----r- --I'll ateri a I �'`------------- No. of compartments------ ....Size's'.�.�/__ t�kiquid depth._. _�---_ _±__-Ca acit ______ _-_ . :'L p Y Disposal Fi Id: Distance from nearest well-----------------Distance from foundation______________'—"Distance to nearest lot line-------------- �NifNumber of lines-----------------------------------Cength of each line------- -------Width of trench----------------------------------Type of filter material-____-__.................Depth of filter material____._____.________--.Total length_-_________-__.___...-____________--.--Seepage : Distance to nearest well_ '___-_Distance f omr{o ,dsfio � --�Distance to nearest orf- 'ne___-_�_____ Number of pits /. Lining ittdterialJ� Size: Diameter•"-�� DePt Cesspool: Distance,'fi=om nearest well----------------- from foundation.____.--------------Lining material-_..._________.____.__-_-:___________ ❑ Size: Diameter- �. }-c_-------- hw -------------- Liquid Capacity-----------------------------gals. Privy: Distance 'from nearest well-------------------------------------_ ------------Distance from nearest buildi.n __ :" g _----fi ----- ---------------------- r- ` __ � Distance'to-nearest lot Zine_-'- - ------------- -----------------=---------------------------- --------------------------�----fes/� - ' ---------------- Remodeling and/or rep if;ng1 (describe):____-_ r?•� �(-_�J _ � /1. __ - ------ Z ---------------- ------------------------- --------� ------------- f /%,�c. - . - Y' . - ---------------------------------------------------------------------------------•-------------------- v w . w - ' ► ------------------- ----------------`J' I�'Ifereby certii'fy that I have pr pared this application and that the work will be done in accordance with San Joaquin County ordinances, State'law/s,' and rules '/d regulations-of he San Jaaqu n Local Health District. ; l/ f � i �,-____ _............... . ._ ____-_--_ (Owner and/or�Contractor) (signed)-------••- ---r---------�-� - - ------- ---------:---;�------ � - --------- ---------------------- gy « - - frfl� f r F - ( ) .... -- (Plot plan, showing size of lot; location of system in relation to wells, buildings, etc., can be p�i cad on reverse side]. i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- •---------------------------------------------- -- --------- ------------ DATE----------- "• REVIEWED BY--------------------------------------------- --------------------------------- - --- - ---------- ------- --- •- -------------------------- DATE---------�=-------- -----•----•----. ------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------- DATE--------------------'-----------------------------------•- Alterations and/or recommendations:_ . ..,�= ----------------- ------ ----------------------------------------'------------- - --------- '"1w - --------------- .. - ------ ------------ -----------------------•------•------ ---------------------------- TM FINAL INSPECTION BY:--------------------- ------------------------------------------- Date----------- -- ~. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 811 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M ; Revised W-2100