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APPLICATION FOR SANITATION PERMIT Permit No. J.- (Complete in Duplicate) Date lssuecl-3:77 _1511_1 Applica+ion is hereby made to the San Jo6quin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with-Co ty Ordinance No. 9 � 5 51 JOB ADDRESS AA LO AT OrN .0. ---------- ----------------- -- ----- - ------------------- ----- Owner's Name. ----- --------- --------------- ----- -- Phone----.,------------------------------ --—---------- - ---- - ------------ -------- -- -- ----------- Address Contractor's Name---------- -------------- ------------------------------------------- __-------------------------------- ----_----------------------- Phone----------------------- --------- Installation will serve: Residence Apartment House F� Commercial [] Trailer Po ofel J Other e _Ef I v6otez_�, Number of living units: I`Number of bedrooms ----Number of baths td?�etw---------/ X__ A Water Supply: -Pub;ic system 0 Community system E] .Private) r' Depth to Water Table PC ff. Character of soil to a depth of 3 feet: Sand E] Graver Sandy Loam Ej Clay Loam E] Clay Ej Adobe ❑ Hardpan E] Previous Application Made: Yes Ej No K New Construction: YeSx No F-l TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep is Tank: Distance from nearest wel#---!7p --------------Disfancpafro rrLfoundaf ion---?_�__.Mafe I_____6�1�01 No. of compartments----�1�-—-------- -----Size----1�,X_S_Liquid depth_------------ ------------Capacit y- Dis,po al Field: Distance from nearest.weIL___.__ - --- -.-Distance from fo'undaf ion--------------------Distance to nearest lot line_______...-______ El Number of lines-----------------------------------Length of each line----- --------.-----.-----.-.Width of trench-_---------------------------_- _ Type or' filter material-------------------------Deofh of filter material-----------------------Total length___-____________..______________--__-__ Seepage ength----------------------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line.____.__-________ ❑ ine---------------- El Number of pits----------------------Lining material-----------------------Size: Diameter---.-- - Cesspool- Distance from nearer i w - - ------------Distance from fpounndd fion material-----4 _Liquid Capacity-------- Size: Diameter-------- I -------Depth-------.- Privy: ------Depth---------Privy: -Distance from nearest %yell___"_i�- ----Distance,from nearest building- ---- ❑ Distance to nearest lot line- -- ----- _4 :_ -- -------------------------------------------------------------------------------- ----------- Remodelingand/or repairing.(describe):_a$%we---A&AK- ---------------------- -----------------------------•-------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------:------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- -----------------------------------------------------------------------------I----------------------------------------------------------------------------------------------------------- ----- I hereby certify that I have pr7pared this application and that the work will be.done in accordance with San Joaquin County ordinances, State laws, and rules�end regulations of the San Joaquin Local Health District. (Signed)-- ----------------------------------------------------------------------- ------ -(Owner and/or Contractor) .Br-----------------------"-------.------------------- -------------------------------------------------------------------------- ------(Title)----------------------I——------------------------- --------- plan, ihowing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- - p4DATE-- - -- .-_ --: _ _ ----- -- ------------------ REVIEWED BY------------------------------ -- - DATE- -7---__ A—---------- BUILDINGPERMIT ISSUED------------------- ------------------------------------------------------------------------------- DATE--------------------- Alterationsand/or recommendations:------------------------------------- ------- .......... ---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------11-1-1----------- -------------------------------------------- ----------------------------------------------------------------------------------------- -------------------F •----------------------•---•--------------------------------------------------------------------------------------------------- ----------------------------------------------------I----------------------------------------------------------------- -------------------------- _X ------------------------------------------------------------- 0-4----------�_, ------4--------------------------------------------- --*-- ------ ------------------------------- --- ----------------------------- FINAL INSPECTION..BY:------- --------- -------------—----------------------------- Date---------------5-- -- ----------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100