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aAPPLICATION FOR SANITATION PERMIT Permit No. _63-2-Z_ _. (Complete-intuplicate) Date Issued ___5�Pls�_. rl�pplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinar�cecNo: 4� �.. = --------•----------- ------------------- s JOB ADDRESS AIJQ OCATION_.. - Owner's Name_ : . ` . = _ =---------- --------- ------------------------------ ---- -------- Phone"-. ---------------------- ------ Address---------- �_. '_. E'`-�1j+° .• -.. -------- ------------------•------------- - --------------------- Address Name--- ----------- Phone w Installation will serve: Residence` Apartment House ❑ Commercial ❑ Trailer Court ❑ otel�❑ Other ❑ Number of living units: ___I--- mber of bedrooms Z__ Number of baths 1_- Lot size __.�_ ------------------ 1_-Water Supply: Public'system Community system",E], Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sana Gravel E] Sandy Loam Clay Loam E] Clay C] Adobe Hardpan ❑ Previous Application Made: Yes [I: No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , Or (llo septic tank or cesspool permitted if ubl sewl:r is availablewithin 200 fee+.? d � ._- ....... ..__ istac� f o oun atirbn. /: Mater,alf- Septic Tank: Distance from nearest well___._°. No. of compartments---__-.-- - -d-----`-:S1Z � ---Liquid gepth -- ----------Capacity___- - r Disposal/Fie4d: Distance from nearest wel __..�.-_ iistance from foundation_/ ____!r"- Distance to nearest lot i e __ }� x Number of lines______.__" .._. Length of each,line____________ _0" Width of french_._.._`_�j__ . . '� Type of filter materi f. '- Depth of filter matenaL...____�_�' Total length_______________ ___�tf_ -.________._ f} Seepage Pit: Distance to nearest well____._." ___Distance from foundation____________________Distance to nearest lot line.... _ ❑ Number of pits----------------------Lining material------ ------= -- Size: Diameter Depth Cesspool: Distance from nearest well _______________Distance from foundation-------------------.Lining material--------------------.------___._____-. 4, Depth y Liquid CapacitY- ----------------------- gals. CV` ❑ Size: Diameter__:`------- ---------------------- ----------------- - - Privy: Distance from nearest well-__--- ------------------------ _________________Distance from nearest building------------------------------------------ -------------- ❑ Distance to nearest lot line------ -------------- ------------------------------------------------------------- Remodeling and/or repairing (describe)-------------------- --=---------------•-----'- --------•----------------------•-•----------•--- 1 6 .._--.--_._______________________._____-.-____________ {1 ' E _______________________________________________________ ___________________________ I hereby certify that I have prepared +his application and +kat the work will be done in accordance with San Joaquin County ordinances, State laws, and Iles and eguiations of the San Joaquin Local Health Dis+rict. t C _.____ (Signed} (� ! - tf,A _ Owner and/or Contractor ( ) : EIa ------ ------------------------------ (Plot plan. showing size of, locati n 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 - ----------------------------------------------- BUILDING PERMIT ISSUED--------------- ------ DATE-------- --_ Alterations and/or recommendations------------ -------------- -y- ---------------------------------------------•----------------.---------------------------------------------------- ---------------- .. ?i l---- - -----------------------------•-- •--•--------------------•- ---- ---- -------------------- . ---�----- �3 a,-�-------------== U `�dllf 7------------'^........ /f'1� �r �a = 1 /� ." �l�rf ------------------------------------------------------------------------------------------ FINAL INSPECTION BY-------------- -- -�.I 71111A --------------- Date---- -----—- -------._5...------. ------------------------------------ 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 145446 PTwnoo 12-54