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APPLICATION FOR SANITATION PERMIT Permit Nolc::�-117- 4 ►� (Complete in-Duplicate) � Date Issued ------�?.. -A Ij ion is hereby made to the San Joaquin Local Health District for a permit to constr t and install the work herein described. T�I.i application is made an compliance with County Ordinance No. 5491 : JOB ADDRESS AND -OCAON-- - ,� . ' Owner's Name �10 :. , - ,..�.� --- - ---------- Pf----------- one__ Address------------------------- ----------- Contractors Name ------ Phone.... Installation will se` e: Residence Apartment House p ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number o living unit: Number of bedrooms,.__ Number of baths___ Lot size Water Supply: Public system''Communitysystem - Private '� ' `=- Y ❑ ❑ • Depth to Water Tabl ft. Character of soil to a depth of.Tfeet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeT'�Hardpan ❑ a ' Previous Application Made: Yes ❑ No1�( New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we1l.,,-:+,,...e-"_,Distance from foundation-____ Material______ _ y.__ _ "V No. of compartments____--a--------------Size____.-________.-----------------Li 'a quid depth--------------------------Capacity.----- ------------- Disposal Field., Distance from nearest well------------------Distance from foundation-------------------_Distance to nearest lot line_________________ Number of linos Length of each line Width of trench ---------------- Type of filter material_________________________Depth of filter material----__-----------------Total length--------------..._____ _ - -------------- Seepage.Pit: Distance to nearest welly+.!t ___Distance fr m fAun a#ion___-______________Distance to nearest lot line Number df its. Linin materialSize: Diameter_ -�� p g -------.Depth------J ---------- Cesspool: Distance from nearest we!f-----------------Distance from foundatier--------------------Linincjinaterial_______-_________-________________.. ❑ Size: Diameter Depth -------------------------- --------------------Liquid Capacity -----------------gals. F Privy: Distance from nearest we] -__..--- ------------------------------------_ Distance from nearest LM)clin g ❑ Distance to nearest lot !ine- �.- ---------------------- -f-- ------------- ----------------------------- Rmod 1,)11g and/o repairing {describe}:--____ - �'/ r -------/";�-_,�c�r-!-- / �; � .7 - - ��- , - ,, 4. -�� - . . - --� - -�' .. . _ 4:•-fig' . �- -- �- --------------------------�------------------------------------------------------------------------------------ --------------------- , I hereby certify fhaf Y_9�1 ared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfate-laws, anregulations of the San-Joaqu' -Local. Healfb District. {Signed) -------------(Owner and/or Contractor Y•__--------------- ------- ------- -- _ - �----.---=`---- ------------------(Title)---------� =�'_'-=��----- (Plot plan, showing size of I`ocation system i,,,.6elafion to wells,`buildings, etc., can be placed on reverse side). .�- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYDATE_ ---------- ------------------------------------------------------------ REVIEWED BY = --- ---------- - ---------------------------------------------------------•. DATE------ - BUILDING PERMIT ISSUED------_------------------- •---------------- --------------------------------------------------------. DATE--•--- - ---d.------------------------------- - ---------- A terations and/or recommendations: - – -------------------•--• •--•----------- ------------------------------------------------------------------------------------ - rft ? I, --- ------------- = ---- --- - - ---- - --------------------- C - s ]NAL 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 8-51 Revised W-2100