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,. APPLICATION FOR SANITATION PERMIT Permit No. —/Z.2-2n.0 (Complete (Complete in Duplicate) / Date Issued Application is hereby made to the San Joaquin Local Health District for a permit toonstruct and install the work herein d�d This application is made in compliance with County Ordinance No. §,19. , JOB ADDRESSLNID LOCATION � kh� �'-�.,�c' (��---------------------------••-.----• --------- Owner's Name--- — ( -e-C.t2- � 1 d- ----- Phone` ' ? Q "�, Address`" :f37-_1 - --- ...Co----- 46#1-�)! / Contractor's Name... Installation t Phone.- fj�[�l -• Installation will serve: ResidenceV Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ _ Number of bedrooms ,_/-__ Number of baths _-1-__ Lot size •--- .�...—_--------------------- Number of living units: --f Water Supply: Public system ❑ Community system ❑ Private Fr--Depth to Water Table ______-_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe O''Ftardpan❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No Q--MA/VA: Yes❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or',cesspool permitted if public sewer is available within 200 feet.) Stic T4nk: Distance from nearest well-----------------Distance from foundation--------------------Material------------------- DdI`IIftq No. of compartments----- --------- -----�-Size-----------------------------___Liquid depth-------------•------------Capacity ----- n r � Dis oopl �ield: Distance from nearet well ....Distance from foundation.__ Distance to nearest lot line t!&4S;rj r1g Number of lines------I---- ------ -- - - -Length of each line----CO-_� ________.Width of trench.:PX_��_-.��-_-. __....... „} Type of filter materiaL_ ��IC-+__Depth of filter material____1_$H________Total length..........fin_ ........._......... Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______________-__ p Number of pits----------------------Lining material-----------------------Size: Diameter_--_-------------------------Dept Depth-----..............,-------- 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__________________________________________ ❑ DNfance to nearest lot line--------------------------------------------------------------------------------------------------------•--•------•----------••----••••------ Remodeling and repairing {describe)- -------- --------- ------ ------------------- -----------•---________ -- ------- ._.___--•----•-• ................ ------------- --------------------- I hereby certify that I have prepared this application and that rk will b done in accordance with San Joaquin County ordinances, I s, and rulesganregulations f the S oa m Lo al Healt istrict. (Signed)•- •••- w1 I+ --• ---- -------- --- -------------- --------------- ontractor) gy.. ---- ----- - ..(rifle) ----- (Plot plan, showing size of 11t, location of system in relation to I 'Idings, etc., an be placed on reverse side). FOR DEPARTMENT USE ONLY d 4 APPLICATION ACCEPTED BY------------------------------------ - ----- - ------------------------------------- DATE............. - ................. REVIEWEDBY----------- - �j ---------------------------- DATE--------------------------------------------------•-----•- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-- -------•--------••--------------------------------------- Alterations and/or recommendations:--------------------- -------------------_--- -----------------------------------------------••-------------•----------------............................. --------------------------•--------------•-- ................---------- •------••--------•-•----------------------------------•--•-----•-••-••--••---•••••••----..............................------------------ ------------------------------------------------------------------------------------------------------------------------------.............................................-----------------............................... ------•-•---•-•--•-•---------------------- ----- ---------------4f-------1'=...------ --------------------------------- •-------------- 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 Revised 1.57 F.P.CO.