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V�� APPLICATION FOR SANITATION PERMIT Permit No. ------ Ix ...___. ,r+f (Complete in Duplicate) -- Date Issued ---------- 3 � T Applica-1-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 No 49. JOB ADDRESS AND L C ION- --- Owner's Name------ = O.f A1A_A1-- - Phone Address F --- •----- Contractor's Name----49_!-_Z__ � - - Phoneh/F_'__4___ ©-7 Installation will serve: ;Residence 20 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ,.Number of living units: ---I_ Number of bedrooms __ A_ Number of baths J-___ Lot size ------1�-Q___"`----/_574_._ --------------•------- Water Supply: Public system ❑ Community system ❑ Private M Depth to Water Table -0__ ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ Previous Application Made: Yes ❑ No [,� New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) R Septic Tan Distance from nearest well-----------------Distance from foundation---------------___Material----------------------------------------------- of compartments-- -----------------------Size----------------------••--------Liquid depth--•------------------- --Capacity---------------------- 1 - Disposal Fie Distance from nearest well----/4v__-_.-Distance from foundation----�6=a_�___.___.Distance to nearest lot line_---r_2------- Number --____Number of lines-------------- Length of eachline- 5�--.�---___._.Width of french.______�_S6_'-_.------------- Type of filter material---/_�-------�a7*epth of filter material--_/�_______.._-Total length___.-__A,f'____________________------ Seepage I'i Distance to nearest well__-_�_YD_�______Distance from foun ate _l _Distance to nearest lot line_--_-__�_______ Q of pits------./ ?fe*. jameter.__ Number. p _Lining material �,��---�--------- Dept h-----,�+�---- ----------- I ' Cesspool: Distance 'from nearest well-----___________Distance from foundatidn.u._Y -_F_: "_ Lining material---------------------------------- Size: _.____-_____-___._.______--____Size: Diameter--- ------=-------------------------- Depth----------------- t---Liquid Capacity----------------------------gals. . � r' _ g_!--:----------------------------------- Privy:' ' Distance from nearest well--------------------------------------------------Distance from nearest buildin _ ❑ - -Distance to-nearest lot line--- ---------' =--------------------- ----- ------------------ --------------------- Remodeling ---- -•-•-- Remodeling and/or repairing (describe):----------------- =-------------------------- = ::. - I . - --•-•---•-----------------•--------------------•------------------•-----•----------------------------- i -------------------------------------•- ... ------- - _....---•----------- --- - -•-----....--------------------------•----------•-------••------•---------•---------------- ------- ------------------------------------- + I hereby certify that-Ihave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws*and rules and regulations of the San Joaquin Local Health District. (Signed) �- -:-:-.-- /�- "-__ — -------------------------- ------------------------------ - (Owner and/or Contractor) - By:_ a.------ -- - -_` - - (Title)------z�----- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- --------- _- -------------------------------•----=----------------------- DATE----- .� REVIEWEDBY--------------------------------------------- ------ --------------- ---- -----••----------------------:---------------- DATE------ ------------ ---------- ------------------- - ••----- ----------------- -----------------------------=-------- DAT � = Alterations and/or recommendations--------------------- --- ---- ----------------------------------------------------------------------- BUILDING PERMIT ISSUEDE - -----------------••--•-•-----------•---------------•------------------------------------ ---------------------- ------•--•-•-----------------------------------------------• t ------------------------------------------- ------------------------------------------------------------- ---------------------------------------•-------------------=------------------------------------------------------- FINAL INSPECTION BY:- Date__ - SAN J JOAQUIN LOCAL HEALTH DISTRICT 11 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street f Stockton, California Lodi, California Manteca, California Tracy, California J ES-4-2M Revised W-2100