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'yp APPLICATION FOR SANITATION PERMIT Permit No. 4---------j---- e ---- OY 1 (Complete in Duplicate) Date Issued Y j-0_/ Applical-ion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described, This This a plication is made in compliance with County Ordinance No. 549. a plication ca rion OB ADDRESS AN j LOC ATI 0 -------------- Cx-,.•__... �_-•- wner's a m ..t' wner s Nam ----A-------- -------- -A k-------------- Phone__ ,7 Address----------------------`-5- A ------ ... ......... _0�. _7---�_e_ ..... Contractor's Name. ---- ----------------------- -❑--------------------------------- Phone--- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel [_1 Other E] Number of living units: Number of bedrooms -4. Number of baths -/--- Lot size JIM–!---X'Al-62---------------------- Water Supply. Public system ❑ Community system El Private [+Depth to Water Table aka. ft. Character of soil to a depth of 3 feet: Sand F1 Gravel El Sandy Loam El Clay Loam E] Clay El Adobe 0Hardpan E] Previous Application Made: Yes E] No 1KNew Construction: Yes No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic;ank: Distance from nearest well----- ____Dista f �oun�qfion------ -------- -_Material 61 ��---- --- ro Ta ------- --------Capaci y---- ------- Eel No. of compartments-------- a-------------Size-U) ---�� _Liquid clep'h---- D;s Field: Distance from nearest welf----- Distance from foundation--- ----.Distance to nearest lot line. Number of lines-------------- Length of each line________ Width of trench._.._..._ - -.- e- Type of filter material- 19----- ------ - --Depth of filter material--- --------Total length----I 5_0--------------------------- il Seepa Pit: Distance to nearest weff---- -----Distance from fou clafion---JAP.....D' ane to nearest ]of line!_- ___0-24 --- To 7 N Number of pifs------/-------------Lining material--(7 ---- ------------ -------------Size: Diameter-----Y-4- Depth----- -------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-____- Size. Diameter------------------ -------------------zDepfh------------------------------------------------------Liquid. Ca pac ity._____ Privy: Distance from nearest well-_..-..._---------------------- _-----------.-Distance from nearest building_--_-.--_-._--__________...._.___.____.__ Distance to nearest lot line-------- Remodeling and/or repairing (describe):---------------------------------- ...... --------------_--------------------------------------------------------------------------------------- -----------•-------------------------------------------------------I--------------------------------------I-------------------------------------------------------------------------------------------------------------- -------------------------------------------I---------------------------------------------I---------------------------------------------------------------------------------------- ----------------------------------------- I"�t ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State�Iaws,.Aan rules, and regulations of the San Joaquin Local Health District. ... .......... ----------------------- -------- (Signed)----------------- - -------- --- -----•-------------- ---------------------------------------- j-------_Lww" and/or Contractor By:------------------- --------------------------------------------------------------------(Title)--- -------------------------- (Plot plan, showing size 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--- ...... REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------ ----------------------------- BUILDINGPERMIT ISSUED---------------------------------- ------------------------------------------------------------------- DATE--------------------- Alterations and/or recommenclaf ions:------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ -------------------------------- ----------------------------------------------------------------------- -------------------- ------------------------------------------------------------------------------------------------ --------------------------------------------------------------------- -------------------------------------------------------------- -------------------------------------- -------------------------------------------- ------------------------------------- ---------------------- ----- ------ ----- ---------------------------------- ----------- --- ------- -------------- ------------ ------- ------- --------- FINAL INSPECTION ------ ------ ------- --------- --------------------------------- 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 Revised W-2100