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APPLICATION •FOR SANITATION PERMIT Permit No. `[Complete in Duplicate} _ DateIssued -3�7A3 Applica+ion is hereby made to the San'Joaquin.Local Health District far a permit to construct and install the work herein described. This application is made-in compliance with County Ordinance No. 54.9. JOB ADDRESS AND LOCATION-------- 1r 7` - Owner's Name-------------- _ ________________________��•�,.�T "--- --- - 1---------' .. , f-------- -------- --.-�7a Phonv� -Address________ � � _________ - F - Contractor's Name --- �- ----------•---- ;--------------------------•---- ------------------------- Phone will serve: Residence ❑ Apartment House - - ❑ Commercial [) Trailer Court ❑ Motel e Other ❑ Number of living units: -------- Number of bedrooms -_6-'Number:of baths .-6. Lot size _____________________ __ - tom- -•---- Water Supply: Public system ❑ Community system ❑' Private;k• Depth to Water TableC�+ft. Character of soil to a depth of 3 feet: } Sand ❑ Gravel E] Sandy Loam [] Clay Loam Previous Application Made: Yes E] No j�- Yes* `New Construction: YesNo ❑ y El Adobe E] -Hardpan L]TYPE OF INSTALLATION AND SPECIFI'C`ATIONS: (No septic tank or cesspool permitted if;public sew is available within 200 feet.) - - Septic Tank: Distance from nearest we - � _Distance from'foundation--------------------Material-___-___ff � No. of com artments --- --- - -- -- P `�-� i.__Size.... Liquid depth-------------------------Capacity Disposal rField.- Distance from nearest well_/�-----,Distance from foundation_j -------------Distance to nearest lot fine____ NumbeNumber or lines------------------- 1,06--- r of each line---------------------------- Width of trench-- -�--- Type of {filter material__ "Depth of'`fiiter material_ ------- Tofaf length Pit: Distance to nearest well-----_-y--------------Distance from foundation-____-------_------Distance to nearest lot line-_-._-_____---- { ❑ Number of pits------'- --- Lining material-----------------------Size: Diameter_--------------- Cesspool: Distance from nearest well..- ------------ r g Depth----------------------•--- ; Distance from foundation-_.__-____-__.- -.Linin material-_________________ . Q - ... .Sizes-Diameter.=•: =-=" -_-- Depth_-= ------------ - ---•=:'4'"-*.,_.Li ui.d=Ca aci ' Privy Distance from nearest yell__. ------ - _------_Distance from nearest building 171 .�. . Distance to nearest lot line''*"-_•-'- �:'-- -,-_ - -__ _� Remod' eliX r r ng and/or repairing (describ - e):.-_,� - -- ------------------------------- . 7 - ------- ---------------------------- ---------- ••-•--------•-------------- ------------------ -------------------------- ` I(� = -------------------------------------------------------- ..y1�► I"herebcertify}haf I have prep, ed this• pplication a d that the work will be done in accordance with San Joaquin County •ordinances,`Statte 'laws, andrrul an regulatio s of the S- Joaquin Local Health District. it i i .. ;_ ---- ---s-------�-•------- -----•-- ------ --(Omer and/or Contractor) By: ------------------'-------------- ---------- (Title} -- - --------- -------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc.,.can be placed on reverse side). FOR DEPARTMENT USE ONLY-' r1PPLICATION ACCEPTED BY__--- --_-- ------------------ __. DATE 5 REVIEWED BY ----- = ------------------------------- BUILDING ------------------ ----------- -------- - DATE--------------------------------------------- PERMIT ISSUED:;'�':--------'--------_-•- � ----- � --------------------•------------------- •- ----------- DATE------'------'--- --------- - --------------------- A terations and/or recommendations:---------------------------------- ------------------•-•---------- ---------------------- -------------------------------------- ------------------------------------------------ ----• -•-•-----•------ ---------- ----- '` - ' - - = .c....-..... - -------- FINAL-INSPECT10*--BY.-___ - ----_ -- - --` -- - s --------- — -- --------------------- '�--•--Date--�-�-•:�-.� SAN JOAQUIN LOCAL HEAL DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street. �F Stockton, California 814 North "C' Street • Lodi, California Manteca, California } Tracy, California ti E5-9-2M Revised W-2100