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APPLICATION FOR SANITATION PERMIT Permit No, __ _______,! (Complete in Duplicate) I r ate Issued . Appli Thca ion is hereby made to the San Joaquin Local Health District(�5 r YaXni gans`trucctt„and�install the work herein`described. This application is made in compliance with County Ordinance No. 5JOBADDRESS AND LOCATI . - --------- -- q Owner's Name------ ----- -- -------- -------------------------------------- ------ ------- ----------------------------- Phone---- `f �� ------- Address-------------------------- - --.....1_4- --------- WE-e-S,. /1%Z-6.1 Contractor's Nam . _ .. ~~ -, m --------- lE Phone_�f_Jr__;rr_,G'T Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I------ Number of bedrooms ---I- Number of baths -l_--_ Lot size ._l_ ! Q_ _ _______________________________ Water Supply: Public system ❑ Community system ❑ Private 9 Depth to Water TableZs* ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe N( Hardpan ❑ Previous Application Made: Yes ❑ No', New Construction: Yes 4, No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_=` �____Distance from foundation_/O____..___..Material--- VIlt7_--------------------------- t9 _____---p__-__ ________I t9 No. of compartments----171-- ___-----------Sizeg_X_�_�_X_f�__Liquid depth_"___ Capacity_rseo Disposal Field: Dis tance from nearest well O _...Distance from foundation______..___._Distance to nearest lot line__.��R1 Number o-i lines___._ ^y __ ___________Length of each line__-� ___-_ r7 Width of trench..��_ ________________Type of filter maferial_�- -- W<I__Depth of filter material___.-1-- _ Total length___-527_ _______11 See a e Pit: Distance to nearest well-_ Distancromdation___ ___ _.p g ► �� _ � �_._____.Dista�ce to nearest lvo�t Number of pits." --____Lining materia1_914-CZ.Size: Diameter---33.______.____Deptn.-c!--�_-____-._ ' Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material-.___-._.__________________.__.__.__ ❑ Size: Diameter-------------------------------------Depth------------------------------------------- ----- - Liquid Capacity------------------ ---------gals. Privy: Distance from nearest well __._______.-----------------------------------Distance from nearest building__.-------_------------------------------- ❑ Distance to nearest lot line---------------------------------- ---------- --------------------- Remodeling and/or repairing (describe):- ----------- -------------------------------------------------------------------------- -------- ------------------------•------------------------------------------------ ----••-- ------------------------------------- ------------------ = -••-----------`------------------- .. --------------------- _.r----- -�------------------------•--------------------------------------- --------------- ----------------------•--------------•-----•-••------•---•------------------------------------•---••--•-------------------------•----------------------------------------------------------------------------- -----------------------------------------------------------•--------------------•---------•-•--------------•----•----------------------------------------------------------------------------------------------------------- I hereby certify that' I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, d rules and regulations of the San Joaquin Local Health District. r (Signed) =• - -= • ' i (Owner and/or Contractor] B . ---• -- •. ss * '•�� Title s ' �_ . - r Y• L �. (Title)-- r (Plot plan, showing size of tot, location of system in relation to*ells, buildings, etc., can be plaAon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ - ------------ DATE------------ r` -^-- REVIEWEDBY----------------------------------------------------------------------------------- ---------------------------------------- DATE BUILDING PERMIT ISSUED------------- ------------ --------------------------- --------- ----------- DAT 7Alterati ns and/or taco end tions:_-___ F. 4'' _ } --- "F5[_c tJ-- ----------- ---------------- �, t ----------------------•-------------1�---- ----- -----------------------------•--•- -------- ----------------- -------------- -- ---------------------/��)- --- --:-•------------------- --------------------------------- ------ - �-.rte .5� FINAL INSPECTION BY:..- Date - ---- ---------- -- 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 ES-9-2M 10-52 Revised W-2100