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f (-7t-2-60- 3 b '1 { r\�y� APPLICATION FOR SANITATION PERMl7liDuplicate) Permit No. --_71__' 7 =� � Compete n upcae) 7� /St ' 7� { Date Issued -------- ---------- ell Applica�ion is hereby made to the San Joaquin Local Health District fo a p unit to construct and install the wo I eei�f de ribed. This application is made in compliance wit o y nar ce S JOB ADDRESS ND LOCATION-=------•----- ---------- - ------------- ----------- F --- --Owner's Name.- - Addressn,p.► ....-�-------- , Contractor's Name_ -- Phone- 3 --------7 Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _A--- Number of bedrooms -A---- Number of baths A_--- Lot size ------- __. ---------------------------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4:( ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E?" Hardpan E? Previous Application Made: Yes ❑ No E? New Construction: Yes NJ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` ]� i(No septic tank or cesspool permitted if public sewer is available within 200 feet.) a Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ____-_--..--.-...----.-----__-----._--.--.._-N �~ No. of compartments------ ------------- -----Size-------•--------------------•---Liquid depth------------------------Capacity---------------- ------ .171, Disposald: Distance from nearest well............-----Distance from foundation--------------------Distance to nearest lot line.-------___-_....` °GSL a�I N Number of lines------_-------------- ------------Length of each line--------------------------.-.Width of trench-------------------------------- Type of filter material-------------------------Depth of filter material----------------------Total length---------------.----_------_--__----__-..- SeepacpPit: Distance to nearest well....1.-----------Distance from foundation_--.-Q.... _-_Distance to nearest lot line__(5_'_+.-. Q% Number of pits-------L-------------Lining material--�A!--------Size: Diameter----.--1 ...- -_--Deptn____--2+ -----------__---- 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---_:.__---.----------___----------_------. ❑ Distance to nearest lot line------------------------------- -----------------------------`------ •----------------------�------------------------------------------------ i� Remodeling and/or repairing (describe): . --•._V.SIA ---•--p" w �` "i`.._ ------------------------------------•- --------- +."_ -------------------------------------•--------------------------�-- -------- i -•-••----------------•----------------------•-•--------•-•----------....-------••-----------------------------•--•-------------------------------- ` ------------------------------------------------------------------------------------------------------------------------•-----------•---------------------•------••-------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)_.____ --_--t ._---.-_ -._-(Owner and/or Contractor) ----- -- --- ------ --------------------- By--------------- - -------- ------- ---------------------------------------------------------------{Title) -" 11 (Plot plan, showing size f lot, locatio of system in relation to wells, buildings, etc., can be placed on everse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------y DATE----------------� --------------------------------------------------------------------------- REVIE'WED BY - DATE ---•--•-------------•---------------------- ------------ - -- BUILDINGPERMIT ISSUED--------------- - ----------- ------------------------------------------------------------- DATE---------�� Alterations and/or recommendations: ............ -_ ------------ '1 r� -_ --- ----------------------- ------------•----------------------•-----------------•-•-•-------•-- ,r� �/ - --- - ----- --- ------------------------------------------------------------------ ----------------------------- .�:.:-- - ----— ----------------------------------- , r �j - -------------------- -- ------------ Date- 1 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, California Manteca, California Tracy, California E5—i-2M 145946 ATWDOD 12-6a