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APPLICATION FOR SANITATION PERMIT Pe` rrt No. (Complete in Duplicate) _ 1 '77 VV Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thrs application is made in compliance with County OrdinancV3, JOS ADDRESS AND LOCATION--------------------- ------- --- /=v'--- ------------------------ Owner's Name--------- e " �] V1---�',-.: /e---- ��'1 ? Phone_-Z_&4F �` Address - -------------5 f�7 �: r— -------------------------------- r ------ Contractor's Name _ �sar� Phone----.��--=f�-� - t a Installation will serve: Residence � Apartment House ❑ Commercial El Trailer Court ❑ Motel ❑ Other ❑ Number of living. units: __ --_ Number of bedrooms of baths __1__ � . Lot size --- �------- ---�-�--� ' -----•---------•- Water Supply: Public system,19�_Community system ❑ Private ❑ Depth to Water Table, E,ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] ClLoam C] E] I] Adobe J�� Hardpan E]Previous Application Made: Yes [_1 NOXI New Construction: Yes El No Eli f ` � a srs ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i5pfic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material --__---.-._-__-._--_----____-_-___----_------___. No. of compartments--------------------------Size-© --------------------------------Liquid depth Capacity ------------------•--- isposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line---------------- 0 . Number of lines-----------•-----------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------- Depth of filter material-----------------------Total length--.---__-----_--__-_ - --------------------- Seepa Pit: Distance to nearest well-A6? _____Distance rem fou�ndation___!/•----_-_--_.-. / r� t ce to nearest Igt line --a-_---_ Number of pits------;/-_---.-_--_-Lining material____,_____ ._u Size: Diameter__ _-____._.Depth----d!_ !__.--------- -1 -- -- { ;_Cesspool: Distance from nearest well_----______--.--Distance from foundation____________________Lining material____---.-_-.---_--_--___-_ -------- ❑' Size: Diameter--------=-----------------------------Depth------------------------------------------------•---Liquid Capacity gals. Privy: Distance from nearest well------- ____________ _----_--Distance from nearest building------------------ g----------------------- ❑ Distance to nearest lot line-------------------------------------------- Remodeling and/or repairing (describe)----------------------------------------------- ---------------- -------------- w -----------------------------------------------------I------------------------------------------------------------------------------------------------- -----------------------•----------------------------------------------------------•-------------------- --------•------------------------------------------------------ ----------2-11-------------------------------------•---------------------------- --------------•--------------------------------------------------- hereby certify that I ha�✓a repared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rfilesnd regulafiions of the San Joaquin Local Health District. (Signed) (��, �(1 l s_ / '--- . Owner-a ./,or Contractor) sY� ----- F b = Titlere-7- (Plot .:tet - - plan, showing size of lot, locatic of system in relation to wells, buildings, etc., can be 101-aced on reverse side). , FOR DEPARTMENT USE ONLY ------------- APPLICATION ACCEPTED BY---_ __ DATE --------------------- `_ ___ REVIEWED BY --- ............................. -- ------- - ------ DATE------ � BUILDING PERMIT ISSUED------------------ DATE �Qy%-------------------------------------------- ----- ----------------------------------------- Ateraticns and/or recommendations:_______________________ ------------- -------------- -------------------------------------------------- ------------------------------------------------------------- ------------------------------------------ -- ----------- --------------------------------------- - � / r ------------------------- FINAL INSPECTION BY:--------LAI A /--�--- - --------------------------------- Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 8-51 Revised W-2100 1