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} APPLICATION FOR SANITATION PERMIT Permit No. __" _..'1`v Complete in Duplicate) �. s.v Date Issued __.._. .____�.___.___ Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This - , ,. A3. r ADDRE S AND LOCATION - ------ (Db E_Owner's Name---•- � 5 4 � - + - - �.c1_ � Phon V-1------------ 7 Address------------------------ �� ----------------------- _4��-- --�-�.� .3; --------------------- Contractor's Name------ m -_P _ ..R�-------- -- ---------- ------------ ------------ Phone........--------------------------- a 'Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ W Number of living units: a---- Number of bedrooms __ -Number of baths -�-- Lot size _---_-I-..-�� t 1��,;-i--__ {N ------•----------- Water Supply: Public system ❑ Community system ❑ Privateepth to Water Table -------- ft. [b 0 ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sanam Clay.Loam ❑ Clay ❑ AHardpan ❑ Previous Application Made: Yes ❑ No-jg[,_ New Construction: Yesj9QNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nn__ Septic Tank: Distance from nearest well--;+5��---_--Distance from foundation-_�_b_-_-__.Material---- 'T ------ No. of compartmens......�-------------Size__2_.��--K�-----Liquid depth---------�--.---------Cpact ---- ---� Disposal Field: Distance from nearest well- _��....Distance from foundatiop--- 0----------Distance to nearest lob kne..�__-_------- Number of lines----____-- Length of each line..... __(�--__ _-_ --------Width of trench-__- -` I_-.-r------ Type of filter materia p g h _ e th of filter material____✓__.__...___Total length--- --- ---__- Seepage Pit: Distance to nearest well.....................Distance from foundation F-1 to nearest lot line___..__-__..___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----.-----------------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___-____-__-.;__.____-._.----_._._..____-. ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------�Ie - Remodeling and/or repairing [describej:_ __-_ -f _ �. ---------------------------••------------.----------------------...--------- ----------------- ----------------------------- ----.._ -------- •---- ---------------------------=-------- ------------------------•--------------------------------•---------------•------------------------------------------------ ------------------------------------------------------- ------ 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.' a (Signed) ? ,. ------- ------------------------------------------------------------------(Owner and/or Contractor) ; By:.-------------------------------------e------------------------------------------------------- --------------------------------(Title)---------- -------------------------------------- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ;; -- --------------------- ---------•--•-------------------- DATE---�s--------------- -- -------------------------------- -REVIEWED - ----------------------------- -REVIEWED BY--------------------------------- DATE--.-.--- --------------------------------------- BUILDING PERMIT ISSUED------------ --- ---------------------------------------------------- DATE----------- -----.j ""Alterations and/or recommendations:--------- --------- —�3------------------------•------------------------------------•-••-------•---- ----------------------- FINAL INSPECTION BY----------------------- Date -- - -- J____,�--------------------------------- 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 145446 A7wnno