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-- 3 ------------- -' - Permit No. ..------•-- APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Dalelssued ---3----�- lJ a 1jq'( Applicatio is hereby made to the San-Joaquin Local Health District 54or a permit to construct and instal!the work herein described. This application is made in compliance Y I i ; - ------------------------------------ JO -•-------------JOB ADDRESS AND LOCATIO __-.__-.-- h ---- - "V71 ---- Phone.--------------- ----------- ys... Owner s Name------------------------ -- -.�:;:�.:a..�. -.� -- - __ --------- --I-- --------- Phone ------- Address-------•-------•-----..�7�_� _ _ - ---------• - ----------- ----- -- - - - r Phone___- --- Contractor s Name____�___ Motel ❑ Other ❑ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer C Burt ❑ --- %if l Number of living units: _ ___ Number of bedrooms __-___ Number of baths __--___ Lot size ___. ft Water Supply: Public system ❑ Commur ty-system-El— riveter' •epth'to Water Table Adobe ardpan ❑ Character of soil to a!depth of 3 feet: Sank�, New ,,Gravel [I Sandy Loam ❑ ay Loam ❑ Clay ❑ k 1 p ❑ s Application Made: Yes ❑ - No Constructio : �Previou pp - TYPE OF INSTALLATION AND SPECIFICATIONS. 1 No septic tank or cesspool permitted if public sewer is available within 200 feet.) / k ( P I E / �� _ ----.Mater al- -- /�!l Septic Tan Distance from nearest yell___ Q_______Distance fromGfoundaiLn uid de ith__.___`j�.-.?� --Capacity-. r ❑ No. of compartments_ Y-:5 � _ a i rr ff 40- ` Disposal Fi Distance from nearest well__(�✓� ____.._Distance from foundation--l- _ ---W dth ofttrenchest I�li�__ N Number o� lines__________ _ _ __-- �ngth of each line__ 0. ----. Total length___-_____.__ r .6-Depth of$filter material----_1_-g-- --- OL 'Type of filtergmaterAal_�- -= •- Seepage Pit: Distance to nearest well----------------------Distance from foundation -_ I st line______._ _._-` ❑ Number of pits-'4-----------------Lining material-------- :------Size: Diameter-------------- ------- i Cesspool: Distance fro nearest well---------------_Distance from foundation-__.-_.. _{__--.Lining mate�t& :- ---�---- i --_Li uid Capacity ' Depth----------------------------- ------------- q p Y ❑ Side: Diamet Tom,,_'------- -=- ---_.__-___Distance from !earest building.t / -y. _ Privy: D'-tonce from'nearest well--------------------- - -`�-- _ ❑ D tante to ri wrest lot line--------- ------- ------- --------------- --------- - ------------ ------- - ---- -- + f Remodeling and/or r pairing (de tribe):--------------- -------------- ------------------------- --------------- ---------------------- ---------------------- •-------- ---------------------- -------------- ----------- and that the work will be done " _______________ y ----------------------------- ----- --------------------- . I -------------------------------------- ---------------reb--certjf that I have repared this application a_.__-________. Health Distnctn accordance with San Joaquin County I hereby Y ordinances, State lawn, and rules and regulations of the San Joaquin Local I Ow nd/or ontractor) Si ned 'C' ----------------------------------------------------------- --- ------------------------------- t. • � � - -------(rifle)----- - _� - By:. -- 1--�--- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). l � FOR DEPARTMENT USE ONLY BATE - a r ` 3---------------- APPLICATION ACCEPTED BY__-___ --_----- -- -------- ------------- -------- --�- DATE REVIEWEDBY- -------- - -- ---------- DATE------------------------------------------------------------- BUILDING PERMIT IS'SUED_ f------"----------------- Alterations and/or re mMen atsbns:______.____ -.--- --- ---•-----•- •------------ --------------- a -------- -•------------------ , ----- ----------------------- - - --------------------------------------- -- ----- --- I�. ------ ------ , Lb FINAL INSPECTION BY--------- ----- --------------- --------- ---- Date---- ------- --- - -. -- -------------------- FINAL ------ ----- ---------------- l SAN JOAQUIN LOCAL HEALTH DISTRICT ik ! 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Tracy, California ! Manteca, California Stockton, California Lodi, California y' ES-9-2M I0-52 Revised W-2100 -