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APPLICATION FOR' SANITATION PERMIT Permit No..-�_./ (Complete in Duplicate) Date IssueJ7 Appl'ica+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 OrdinancC. e,No549 -6--, -------------- p I? JOB ADDRESS AND LOTION-------- ----- - - Owner's Name------------ -- -- ---- - ----- ----------------------------- Phone------------------------------ - --------I-------------- Address---------------------W-6- ---- - ----- ----- - ------- ---- ----- ----- --- -------e:_'�-------A�----- ------------------------------ -------------- Contractor's Name-----=--- -- ---- 6---—----- -- ----- ---I----- --- ---- ------- - - Installation will serve- Residence Apartment Ho's'e [] Commercial [-] Trailer Court E] Motel ❑ Other E] Number of living units: N ber of bedrooms .-,=? Number of baths /_____ Lot size ---- ----------- Water .Supply: Public system' �Zmunify system []`� Private 0 Depfh-t6'WMe�'Table -------- ff. Character of soil to a depth of 3 feet: Send Gravel 0 Sandy Loam F-1_-Clay Loam E] Clay 0 Adobe gi Hardpan Cj Previous Application Made- Yes 0 No ER" New Construction: Yes Na El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__s______________Distance from foundation--------------------Material------------------------------ ----------------- �rirnerits---------------------------Size- ---------------Liquid depth--------------------------Capacity----------------------- No. of comp ------------7 Disp9sal Field: Distance from near!,-st well___Y�......Distance from foundation---2.0---- �Distance to nearest lot line-Z-0------- Number of lines___(� Length of each line___4- ______________Width of french_____- -------------------- Ty'e of filter material -s ._Depth of filter material--- *.........Total length-----tz��-7----------------------- P Distance to nearest _-____Distance from fou D of line--I/---0-- Seepag st well-14"3 anon_ ----------------- n" nearest I Number of pit$ -------Lin-in'g material__._ mefer--r. Depth----- Cesspool: Distance from nearest"well-----------------Distance from foundation.-:_ ,,____,.______._.Lining Lining material--- ---------------------------------- - ❑ Size: Diameter------------- #-----.-----------Depth--------------------- -1----! ------Liquid Capacity------------------------_--gals. ------------ Privy: Distance from nearest wet,'____._.__._- -----________________________Distance from nearest building_____________.__-___-:-_______________._.- Distance to nearest lot line_____________________ - - ----------------------------------- Remodeling and/or re' -------- - --a- ---- - ---- pairing (describe ill - -------- --------------- - ------------------------------------------------------ ------ ---------------------------------------- ---------------- -7-11—--------- -----• ------F----0"'.0------ ---/------ IV -------------------------------------------------------------- --------I--------------------- -----------------------11------------------------------------------ --------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- y I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Courif ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------- 166, . aonlractorl ---------------(Own and/or- -- ------------ .. ...... . . . - - —------------------------------------------------- -- ---------(Title)---- -- ------- ------I -- -- - ----------------- By:......4:5-1 ------ A.-A__19 (Plot plan, showing size of lo+, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ------------------------------------------ �6 - - DATE----------------.-� f ------- --------- --------------------- - REVIEWED BY - DATE _ -------- - ------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-._-------- ------------------------------------------------ Alterationsand/or recommendations:_____- ---------------------------------------------------------------------------------- ------------------------I------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- •---•.---------•-- ---------- ------------ -------t---------------------------------------- ------------------------•---------------------------..... --------------------------------- -------------------------------------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------- ------------------------------------------------------- ------ ---------------------------------------------------------------------z_--------------------- --------------------------------------------- -------------------------------------------------------------------- FINAL INSPECTION BY:..- V--- - Date------- --4--7 -- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Revised W-2100