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APPLICATION FOR SANITATION -PERMIT Permit No. ...3.--_--_!. Com lete in Duplicate) �— { P P Date Issued Vpcation is hereby.made to the San Joaquin Local Health District for a permit to construct and install the work herein described.application is made in compliance with County Ordinance No. 54 pP p I 'f JOS ADDRESS AND L CATION----- /--- ... Owner s Name.--------- c11_l_ / v -------------------------------------- - Phone . Address----------------------••------- -------- ------------------....----------------•-•------------------ ------------------------------F----- Contractors Name-----------------�14__C_�f�._l...�_�___--�-` -------------•-------•----------•------------------------ Phone._1:-.__f& z7------ Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] Motel El Other [I. Number of living units: _Number of bedrooms -�-- Number of baths _ Lot size -1B_OE_A___14fe-r- ------ s Water Supply: Public system ❑ Community system ❑ Private X• Depth to Water Table Y-Q ft. ' Character of soil to a depth of 3 feet: Sand [� Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ 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_____ I--------Distance from foundation--------------------Material____---_--_____._______.._____-.-------------_-El No. of com artme.nts-----------------=--------Size---•------------------------__..Liquid depth---------------- ---------Capacity------------------ ---- Disposal Field: Distance from nearest well_____...'__-__.._Distance from foundation____________________Distance;to nearest lot line------ ----------- ❑ Number of lines--- ------------------------Length of each line-----------------------------.Width of trench:_ Type of filter material----------------________Depth of filter material__-.-___._____0_ _Total length--------------------.----------------- f .._____________e_. Seepage Pit: Dis#ante to nearest well-//10-e,--Y Distance from fo ndation_:_Q____..___.D�tance to nearest lot line--/49 ,e i I e Number of pits_QAfI_)---Lining mate nal_,ml _ _.Size: Diameter__.. _ ___.____Depth p ---------- ------ - Cesspool: Distance from nearest well-------_---------Distance from foundation"`_'______..__--- Lining material__.________.___.___-----_-___._____. ❑ Size: Diameter------ 0-----------------------------Depth---------------------•----- -------------------Liquid Capacity---------------------------gals. f Privy: Distance:from nearest well------------------------- ___Distance from nearest building------------------------------------_____. ❑ Distance to nearest lot line--------------------------- -- ---------------------------------------- C Remodeling and/or repairing (describe}: R -- - K F ! - AV--------�' ' --- -------- ----------- ---•------ ---- ------ ---------------------------------------------- - ---------------------------------------------•--------- - -----------------•--------------------------`----------------- -------- •----- - I- I.hereby certify that I ha .e-pr , red this application and the+ the work will be done in accordance with San Joaquin County ordinances, State laws, an rules an egulations of the San Joaquin Local Health District. t i-_-.-- _--`- Owney and r Contractor) l (Signed)-------- - ---------- -- -- ---- - - - - ----------- By:--------------------------------------- ------- (Ti+le) (Plot plan, showing size of lot, Iota ion of system in relation to wells, buil i gs, etc., can be pla ec on reverse side). FOR-DEPARTMENT USE ONLY ' /S DATE---.-__ i APPLICATION ACCEPTED BY-- - -------- ------ ---------------- --I�.T�--------------------------------------- �, } -�/�-,."'�- --• -,-=-- -------- REVIEWEDBY-----..-_--------------- -------------------------- DATE / BU I LDI NG-PERMIT ISSUED--_---------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------- - Alterations and/or recommendations:--------------- --- --•----------------------------•------•------------------------•--••---------------------------------- -------•--------•--------------------------•--------•-•---•--------•-------------•-------------------------- I -----------------------------------------------------•--------------•-------------------------------------- - ------------------------ F _______________________________________ ____________ ------------------------------- -__________________________________________________________________ _ -__- __...____-_._.__._--____...__.__ - s FINAL INSPECTION BY:. ----- Date SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Scree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California Stockton, California Lo r ES-9-2M IO-52 Revised W-2100