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/ 5 APPLICATION FOR SANITATION PERMIT Permit No&--L_�� _ o [Complete in Duplicate] S`—/ � c � Date Issued ___�!-'�s3 application is hereby made to the San Joaquin Loc Health District for a permit to construct and install the work herein described. This application is made in compliance with ou �Ordinan No. 4 . JOB ADDRESS A LO ON ----------- =.''4 _ - Owner's Name----kvUf•- ------ -- --- __--- Phone------^�~ - V - 2 --------------------- Address- __k _ . ------------------------ -•----------------------------------- ------- -•--••-------- -------------- - Contractor's Name-: ------- --------- ------------------ -- Phone --------------------------------------------------- ---• Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: N__ umber of bedrooms 4- Number of baths __77 Lot size __//_ _ tel. IHSS------�r__�---------------• --------- Wafer Supply: Public system Community system ❑_Private 'De Depth to Water . ❑ p Table ________ ft. n Character of soil to a depth of 3 feet: i Sand ❑ Gravel ❑ Sandy Loam Clay Loa m ❑ Clay ❑ Adobe [9/Hardpan ❑ �y r Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest well-----------------Distance from foundation_____________ -----Material ----------- ❑ No. of compartment-s------------------- ze-------------------------------- der` ------------ -----------Capacity--------------t Dispos Field: Distance from nearest lI_ _.0_ *stance from foundation__ istance to nearest lot 1• e_ of lines_____I____ r -------------- Numberength of each line___________ Width of trench_..__--. A _____ Type of filter mater* t _ epth of filter material... Total length___.____.__1_ i.o_____________ --1- Seepage Pit: Distance to nearest well _-------------------Distance from foundation--------------------Distance to nearest lot line_____._.__.___.._ ❑ Nuyr*} f f pits---------------------Lining material-----------------------Size: Diameter------------_--- ---. Depth.. ------------ Cessp 01'. Distance from nearest well___-_______.____Distancefrom foundation___________________ Lining material__._____________.______--.._--- -------------- ----- SIZE: Diameter--------------------- Depth------ -------------••------------------ ----------Li Liquid Capacity_ gals. --------- Privy: U Distance from nearest well--------------- _____I-___ ------__-------------Distance from nearest building----------------------------------- 11 Distance to nearest lot line..._________________ Rem ell g and/or repair es hbe)______ + n _ g ----- 4 --------- - ------ - - ------------------------------------------------------ +- . - . - - --- --- I hereby certify th t I ha prepar d this application and that the work will be d ne n accordance with San Joaquin County ordinances, St a aw , and rules andr gulati s of the San Joaquin Local Health District. (Sign __.--- _ _. I i ed) t yi�/ -------- -- ---------- 1 ------ ------------- --------•------- ------------- ---- • ----------------"(Owner and/or Contractor) By: -------- ---------------------I---.--- T�+le '� [ )----------------------------------------------- ---------------- (Plo+ plan, showing size of lot, location of s st in relaf n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY-- ------- ----- DATE�r� _ REVIEWEDBY /------------------------------------------- ----- - --------- -- ----------------------------- ---------- DATE --------------------------------------------- -1 -------------------- BUILDING PERMIT ISSUED ... --------------------- DXTE------•------ Alterations and/or recommendations_________ '_ i -----------------------------------------+---------------------------------: --------•-----•------------- ---•---------------------------- } I ----------------------------------------------------- ------------------------------------------------- ------------------------- . -- FINAL INSPECTION BY- -----------!/�.3 -� -�---- ------------- Date----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oafs Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M *o-52 Revised W-2100