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Ou APPLICATION FOR SANITATION PERMIT Permit No. 11___..Z... jr 1.7 (Complete in Duplicate) Date Issued t��!Q ,,'-7✓ Application 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 ounfy Ordinance N o,5 9, JOB ADDRESS AND LOCATION � �r � --------- ---- � 1� -------- ---------------------- ------------_--------------------------- ` Phone_ _ ©Owners Name------------------------------------- - -----=-G ---------J_T Address------------------------------------------------1- -�- '�--------------- ------ -•--------------------------------- /' ------ /�!_' ' ,L�= --'4i � 1= Contractor's Name------------------------------- ------ Phone__ -- ------ Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r .� Number of living units: __/-___ Number of bedrooms __ Number of baths --1___ Lot size ------6 - Water Supply: Public systemW Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] E]Adobe, Hardpan Previous Application Made: Yes ❑ No New Construction: Yes ❑ No [:1 4 i C TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic�.T&nk-. Distance from nearest well-----------------Distance from foundation____-__---_______--Material_______-__________-____________________________ f.V-"p No. of compartments--------------------=-----Size----------------------------------Liquid depth--------------------------Capacity----------------------- D' W sal 1 i Id: Distance from nearest well------------------ from foundation--------------------Distance to nearest lot line----------------- 4,,1 Number of lines-----------------------------------Length of.each line------------------------------Width of trench-----------------------:.---------- Type of filter material-----------------------CDepth 1-----------------------Total length---------------------------------------- Seepage ------------•----------------------- - q , Seepage Pit: Distance to nearest well_ 1 ro oundatio _ -..Distance to nearest lot line--f � - Number.�of pits-------y�-----•-----Lining �at-Size• ameter------- 3�- .Depth--Cesspool: Distance from nearest well______________ from fo ion--------------------Lining material------------------------------------- ElSize: Diameter--------------------------------------Depth------------------------------f--------------------Liquid Capacity-------- -------------------gals. Privy: Distance from nearest well________________________________________________D-sstance from nearest building---------------------------------------.-. ❑ Distance to nearest lot line------------------------------------------------ ---------------------------------•--------------------------------- ------------------------ Remodeling and/or repairing (describe)---------------------------------------------------------------------•---------------------------•----------------------------------------------------- -------------------—------------------------------------------------ -----------------------------•---------------•-----------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, angbrulees and regulationsro#fhe San Joaquin Local Health District. (Signed)----- r _j'� ` �-- ------ � ------------------------- -{-Oav�aer�a`�d�' Contractor) �f SYD-�F_'3r�-------- ---- ---- -�--- - ----------------------------------------- --------- (Tilde) Ate- --------------------- on plan, wing size of lot, Iota+ron of system in relation to wells, buildings, etc., can be p�aced on reverse side). FOR DEPARTMENT USE-ONLY r APPLICATION ACCEPTED BY-------- = �, - ---- --------- ------------------- DATE -�-, ' REVIEWEDBY--------------------------------------------------------- - ---------- ------------------------------------------------- DATE--------------� d--r`- ----------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------- ---------------- DATE------------------------------------------------------------- Alteraiions and/or recommendations---------------------------------------------- --------------------------------------------------------------.------------=------------------------- ------------ ---------- ---------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- ; ----------------------------------------- ----------------------------------------------------------------------------------- --------------------------------- ------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------------------------------------- ----------- Date-------_. f `fix--------------------------- F FINAL INSPECTION BY:__.--__--��..�_ -. ------------- - - -� -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C` Street Stockton, California Lodi, CaliforniaManteca, California Tracy. California ES--9-2M 8-SI Revised W-2100