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rva< urrik—c uot: ------------------------------------- ------------------_----------_------------------------- APPLICATION FOR SANITATION PERMIT Permit No. _.-.._-..__--- -__4. ------------------ - - (Complete in Duplicate) i € `u .4 +LS Date Issued - Z. -�...�� ----- ----I = -This Permit Expires 1 Year From Date Issued `13 -- Aso _f6 Application is hereby made to the San Joaquin Local He A District for a permit to constru t and install ork here'n d f7bed. This application is made in complian i h C unty Ordin n e N . 5 JOB ADDRESS AND L TION______ -Q--,- •--------------- Owner's Name. ---------- Phone ------------------(2 ----------- Address----------------------- ----- L - ---- -------------------------------------------_--_-------------------------------- Contractor's Name------------------------ -•- -- ---- -----• -•------ Phone................................... Installation will serve: Resident ElApartment House ❑ Commercial ❑ Trailer Court ❑ f"l otel 0 Other E]Number of living units: __1__. Number of bedrooms __'2,_-Ku—rnber of baths ----�-_ Lot size -----(0-6...... a!_ Water Supply: Public system ❑ Community system ❑ Private B;K/Depth to Water Table _(_C__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Q"Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes 2 -'_'No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public slewer is available within 200 feet.) i Septic Tank: Distance from nearest well____��----Distance from foundation-___lff-()--------.Mat ri�}1_--- ----- r�_ 1 = No. of compartments----- ?C_ ---- G_ _Liquid depth__.-- _-. ......... Cap acity------ ------ --- Disposal ieId: Distance from nearest well----- __- Distance from foundation , ____. Distance to nearest lot li�te...___�.__..___ Number of lines------------Z I _ -- -_Length of each fine__ ______ -Y-t------Width of trench__ 2- - . Type of filter material___- _____ >'p}h of filter material________ ___________Total length___-_� --------- 'J Seepage Pit: Distance to nearest well----------------------Distance from foundation-_________---_-.-...Distance to nearest lot line__-..--________-- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter_---------------------.Depth--------------------------------- M • Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ materia l_____._._____- __Size: DiameterC _-_-_-.- --------------- ---------- p ----•-----------------------------------------------Liquid Capacity ----------- ------gals. Privy: Distance from nearest well ______------------------------------------------Distance from nearest building______-_________________-_-_ Distance to nearest lot line Remodeling and/or repairing (describe):______________________________------------------------------------------------------- ------------- ---------------------•------------------------------------. --------------------••------------•-----------•--•-----------------------------------------------------•--------------------------------------------------- _hereby ce iffy hat I have prepared this ap lication athat the work will be done in accordance with an Sa Joaquin County ordinances, Sta{e aws, and rules and regulations the Sa aquin Local Health District. (Signed)---- ----•------- ---- ---- --------- - ----- ------------------ -- ----(Owner end/or Contractor) By: ----------------------- --------------------------------------------(Title)-----------------------------------------._..._.. (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). R PARTMENT SE ONLY / \ APPLICATION ACCEPTED BY------------------------ ----- ----------- ---------- DATE---- •r-� j REVIEWED BY •------------- DATE-------------- UILDING PERMIT ISSUED ------ -------------- — DATE Alteraigoilsa /or recommendations:------------------- -- -------------------------•••----------•-•----------•------------------------------------------------------------------------------ ____._____ �__R______ __________________________________________________________________________________________________________________________________________________________________________ ____ ______________________________________________________________________________________________________________________________________________ FINAL INSPECTION BY: ------------ ---- ---.___ -,--..-.------------------ Date_ 7 � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6.9 RevicrD 6.59 P-P.co.7M 6.613