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APPLICATION FOR SANITATION PERMIT Permit No. _1_-J7_--IGl__Q' (Complete in Duplicate), !� Date Issued Application 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 Ordinance No. 5 9. �. JOB ADDRESS AND OCATION._k047- ' /1.! �` '% --- Owner's Name -•- - ----- Phone ----------------- ------- -------- --------- -- U ---------- ---- --- --- ---•------------ ------------------------------------------- •------•-------------• Name--------------------------------- --------• ------------------------- Contractor's ----------------------- ---------------------------- Phone-- ----- --------- --------------- Installation will serve: Residence Apart )nt House ❑ Commercial ❑ Trailer �ourt ❑ Motel Other ❑ f Y Number of living units: _-I Number of bedrooms __.� Numberofbaths -S-6 Lo1�e --_--__-_ ___.___________ _ ___________________-_-_ Water Supply: Public system ❑ Community system ❑ Private ]� Depth to Water Table _ ____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ ; Previous Application Made: Yes ❑ Nox New Construction: Yes Pr No ❑ PHA/VA: Yes ❑ No;k TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if publi 0 available within 200 feet.) Septic Tank: Distance from nearest well--- __________Distance from foundat�l__-_-fd-------Material4i.__ �___)- ------- ------ _ CpacNo. of compartments_______ - e'-------- Disposal Field: —Distance from nearest well___��_._Distance from foundation-----�0------Dista c to nearest lot line._%�4��° •�_� Number of lines------- -...--_---_"_ __ _Length of each - --_--_-- i trench..__-_-7_------ _`---------��-- �) Type of filter material---_ _' lC Depth of filter material----I_ `r-------Total length_--_----- ---------------- Seepage Pit: Distance to nearest well---__.---------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Nur 4 er of pits----------------------Lining material---------------------- Size: Diameter-----------------------Depth--------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--__-.-____-_______________---____. E❑ Size: Diameter-------------- ----------------------Depth---------------------------------------------------Liquid Capacity-:---------------------------gals. Privy: Distance from nearest well__________________________'--------_-__-__.-----Distance from nearest building------------------------------ ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------- , Remo e' rend/o'r'repairing (descri ------- ---------------- 46� r / _ ------------ ----------•--------------------------------------------•---------------------------- --------------------------------------------------------------------- ------------------------------------- ---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and�rules�and regulations of the /Sa`n/Joaquin Local Health Dist rict. (Signed) `� va` �.rf �Cft �YU� /,sh - (Owner and/or Contractor) 1 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-__4 '�� --�_/------------------- BUILDING PERMIT ISSUED---------------------------------- 1 �. L DATE - Alterations and/or recommendations: - ------------------------------- ------_-------------•---------------------•-----•------------------- -------•-----------------------•--- w ------------- --------- _ • ----••--------- -------- ------------- ------------- ------- ----- _a---7� � --� - t, ------------------------------------------------------------------------------- ---- - -•- --- --------------------------------------------------------------------------------------------------------------------- FINAL WSPECTION BY---------------- - - -- _-- Date---------------- /Ki;. _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9---2M Revisea 1-57 F.P.CO.