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APPLICATION FOR SANITATION PERMIT Permit No. 3_6 .4 11 � , (C ' plete in Duplicate) orn Date Issued ----- Application is-hereby made to the San Joaquin Lo-cal Health District for a permit to construct and install the work herein described. This application is made in�cornpliance'wifh County Ordinance N6. 549. 6— --f------------------------------- JOB ADDRESS AND L9CATION----------- --- --- ------- ------ - ----- ------------ ------------------- Owner's Phone--------------------------------- Owner's Name- e�_ JeI64----V--< ----------------------- --- ---- - - ------------ --------------- ---------- -----------------------------Contractor's Name------- --------- Address.- Phone----*_ ------ -- -------- -- --- ------ ---- ------ -- ------ 4414_1�a, -- Installation will serve: Residence Apartment House [:] Commercial E] Trailer'C.i ourt E],- Motel El Other El - -------------- Number of living units: ___/_ .Num6er of bedrooms W,Number of the Lot size ---- Water Supply: Public system ❑ -Co�nmunitFi�ys4�E]- PrivW �D,�tlk f6'Water:TabI.5r>__ ft. F Character of soil. to a depth of 3 feet.'.Sand Gravel E] Sandy.Loam ❑ lay Loam E] Clay E] 'Adobe e_._H,,dpa, ❑ Previous Application Made: Yes E] No Ek New Construction: Yes No El TYPE OF INSTALLATION fAND SPECIFICATIONS: (No septic tank or cesspool permitted if�public sewer is availa6le'within 200!feet.) Septic Tank: Distance from nearest well-----------------Distance from,fodndafion:.......................Material-------- --------------------------------------- No. of compartments.-,---- ----------Size-----------------------------------Liqui d depth----------------------.? C a pacify---------------- ----- W Distance from near D, Disposal I] istance from foundation= --------Distance to nearest lot line_,::�----------- Number t Length of each Width of.treh1ch-------e- ' o' 71-, _.r------------------ Type of filter material_��___ of filter material______ __ ______Total length-'' ----------------------- Seepage Pit: Distance to nearest well----------------------Disfance from foundation---- -------------- Distance to nearest lot line_______.______.__ El Number of pits----------------------Lining Material-----------------------Size: Diameter------------------------Dbpth------------r- ----------- ------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_---__---------------------.--.-_---_ F1 Size: Diameter--_-- -----------------------------Depth------::-----------... ----------------------------Liquid Capa5-.ity-----------------------------ga,17--- Privy: Distance from nearest well------------ ---------------------- ----------Distance from nearest building-._-._-_--.-_.-----_----____--.-._---._._. 171 -Distance to nearest lot line_________._ ------- -------------- - ----- ----------------- ------------------- ------- -------------I-------- Remodeling and/or repairing (describe') --- --- ----- ---- -- -- ---------------------------- ------------I-------------------------------------------------------------------------------- ------------------------------------------------------------- -------------------------------------------------------------------------x �------------------------------------------------------------------------------------- ----------------------------- - -- ----------------------------------------------• :------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County gu ordinances, State s, nd rut s an re---- 16- I ions of theS n Joaquin Local' alth District. (Signed)--------- -- __ - -- ---- --------- - ----- (Ownerand/or Co tractor) By:_.... - -- ---- ----------------- ------ ---------------------------------------------------------(Tif le ---- ----- - (Plot plan, showing sizei.of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ----------------------------------------------------------------------- DATE--- ------------------- ---- ------ --- ------ REVIEWED BY--------------------------------- ------------------ -- ----- - ------------------------------------- DATE--------- ---------;----------------------------------------- BUILDINGPERMIT ISSUED----_------------t-----------------------------------------------------------__-------------------- DATE------------------- Alterations ATE-----------------Alteraflons and/or receirrimenclafions-_'. ---------------------- -----------------1------------�------------------------------- ---------------------------------------- ------------------------------------------------ ---------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- -----------------------------------------------------------------------------I------------------------------------------------ ---------I-------------- ----------------------------------- --------------------------------------------------------- -------------- ----------------------------------------------------------------------------------------- ------------------------------------------------------ --------------------------------------------------------- ------ ------------ -------`-----------------__ ------------------Z---------------------------------------- PINAL INSPECTION BY:.---- -------- ----- ------------------------------------------Date--------- . ------- -- --- -------- ---- - ----------- ----------------- SAN JOAQUIN LOCAL HEALTH ,DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100