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-" APPLICATION FOR SANITATION PERMIT Permit No. t 2 (Complete in Duplicate) Date Issued Ix ' . )� V APp litio� 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 Co my OrdinancePN49,r ?-3 77 1 r_r c�1,g 2b a —�5�0- o Z JOB ADDRESS AND LO ATION..,. ---- -- --- Owner's Name I � f{/ --------JU------ --- - - ------------------------------------------ -------- Phone----------------------------------- Address_..---- .•-- f , ------------------------------------------------ -------- Contractor's Name_------ � Phone------------------•---------• ------------------------------ ----------------------------------------- ---- - Installation will serve. Residence �partment House ❑ Commercial ❑ Trailer Court ❑ `Motel ❑ Other ❑ Number of living units. __/__ Number of bedrooms Z- Number of baths __/_ Lot size _./___�e'r,L_ ---.-------•--------------- r Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 5C`lay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes E] No New Construction: Yes ??--No [I FHA/VA: Yes ❑ No [�� ^^' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) _ A4 - Septic Tank: Distance from nearest well __ --Qistance from foundation____ _ ______.Material__._ K No. of compartments_____A---�j-,--,-�-,�-_`-Size_--4,__,d - -rp:___Liquid depth-_._ ------------capacity----4P -0 Field: Distance from nearest well_1r '______Distance from foundation____ ----__-Distance to nearest lot line__-��___.. ®� Number of lines________ ____________ .__ _ en th of each line_______ Width of trench____- .__�f_____.--_._____.- Type of filter material/ Depth of filter material ____..____.Total length-._- _____________________________ 4 __ ,--- �/ Seepage Pit: Distance to nearer ell---- -----Distance fromppfoun tion____;�w-_____..r�Distance to nearest lot line_--____._.____-- , A e Size: Diameter-+�=�---------- f i Number of pits.______ Ae _____-______Lining material �_ Depth___ ___________________ ' Cesspool: Distance from nearest well-----------------Distance from foundation_-------------------Lining material______________-_____________!_.._._. -. E-1 Size: Diameter = --------------Depth--------------------- -------------------- ------Liquid Capacity---------------------------- Privy: Distance from nearest well ------------- --------- .--__.________-__--Distance from nearest building------ -------------------- -------�-"' . . ❑ Distance to nearest lot line------ ---------------------------------------- --------------------. -------•-------------------------------------I Remodeling and/or repairing [describe]:____..- �aiJr ----- " ' l'. ---------------- ----------- ---------------•------------------------------------------------- I --- ------------------------------------------- --- ---------------------------------------------------------------------------------- -------------------------------------------------------------------- I ------------------- --------------------- -- ------- ------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count; T ordinances, State laws, and rules and regulation of the San Joaqu' Local Health District. � y1 - t, f1(/ _ (Signed) c. = •- - [Owar a°�Cn�Contractor p v ------------------------------(Title)---� 'r - - ----- -------- ---- - =--- - - --- (Plot plan, showing size of lot, Iota+ion f syr+em in.rely+ion to wells, buildings, etc., can be placed on revers side). I FOR DEPARTMENT USE ONLY 7 APPLICATION ACCEPTED BY--------------------- ----- - ---- - DATE-----_-____-- --__t..___ ] - ---- --------------------� REVIEWED BY------------------------------------------------- DATE------- ---- -------•------------ BUILDING PERMIT ISSUED DATE----- l- - i Altera+ions and/or recommendations: ` ---- t -------------------•--------------- f 0--t-- �.4�� j------ A -------------- ------------------------------------- �-X_!_wt'`--------7 �� '! 6.E'D .__ '1 r �- 1------Aja-f--- ---------------- i ----- r�' �' �� "----- - ±' �- --------------------------------------------------------- --- ---------------------- ------- - -- �-- �i � :��-----a. i�c -- 7 - -- �� 3 # w FINAL INSPECTION BY: ----------- Dated'' "'`5 ..(SAN JOAQUIN LOCAL HEALTH DISTRICT _ f. 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street < Lodi, Celifarnie Manteca, California Tracy, California r Stockton, California ES-9-2M , Revisea 1-57 F.P.Cfl1