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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) Date Iss,4 ---------- V------------ Applica-lion is hereby made to the San Joaquin Local Health District for a permit +a const uct a ,6 install the work herein described, This application is made in compliance k County 01clindrice No. 5 • JOB ADDRESS 4N TION__ Owner's Name.r-,00 ------- ---------- ---A-1-5 .... ..... . Phone Address... -- •------------------- Contractor -------------------Contractor's Name---- -------- ----------------------------------------------------------- Phone/591 Installation will serve: Residence El Apartment House E] Commercial F] Trailer Court Ej Motel Number of living units:--------- Number of bedrooms ........ Number of baths Lot size ------ S7 -------------- Water Supply: Public system E] Community system. [] Private bae-'❑ 'Pth to Water Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam C] Clay [] Adobe41 Arrpa, ❑ Previous Application Made: Yes D Nojk-0�New Construction: Yes'17r-�, E] TYPE OF INSTALLATION AND SPECIFICATIONS: Septic (No septic tank or cesspool permitted if public sewer is a'vailable within 200 feet.) p ir, Tank: Distance from nearest welk2?4^,.j( ....Distance from-foundation /40 - ------ ----- ---------Mat rial- ---Liq-,,id -------------Capacity- -- --------- 0400""' No. of compartments- --------------size(s-�------)e., Disposal Field: Distance from nearest ...Distance from founclatign-YO-6 ----I-----------Distance to nearest lot line-- -----------Length of each line__ 62.-_ _.___---.Width of french_ Type of filter material---- _r...... ------Depth of filter material------;J�)-----------Total length----,,,,' 60 Sedage Pit- Distance to nearest -Distance from founclation,r#- -- �- -- Distance to nearest lot line _4--- Number of pits-----/-------------Lining material- ----�._Size: ETiameter---4_e---------Depth- Cesspool: Distance from nearest well-_--------------Distance Distance from foun - Jation--------------------Lining' materia!________- ---------- ❑ - Size: Diameter---------------- - ------------------Depth----------------------------------------------------Liquid Capa city----------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building----------- --------------------------- ❑ Distance to nearest lot line----------------------------------- ------------------------------------------------------------------------------ --------------I--------------- Remodeling and/or repairing ('diascribe):----------------------------------- --------------------------------------------------------- -------- -- --------------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County . ordinances,ASfe fla , an es andregulations o the San Joaquin Local Health District. and (Signed)-- --- ----- - .............. ----------- - ----------- ----------------------- - --------- ------------------------- -------- ------------------- ontractor Z_ BY:--- ------ --- ------------------------------------------------------------------------------------ -------------------------- - --------- 7of showing size l�o� (Plot plan, _,�bca *n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------- -------- ---- --------------------------------------------------- DATECA ------------------------------------------ REVIEWED BY----- -------------------- ---- ------------- DATE---0>3 BUILDING PERMIT ISSUED. - --------------------------------------------- ----------------- ------------------------------------------------------------------ DATE------%1k Alterations and/or recommendations:------------------ .. ........................ I I A .. - ......W\-_--------7---- ------------ -------------------------------------------------------------------------------------------------- ----------------- --------------------------- ---------------------------------------------------------------------- ------------------------------------------------- --------------- ---------I---------------------------------------------------------------------------•----------------------------I................. ------- --------- -----------------------------------------:�------------------- ----- ----r----------------------------------------------------------------------- ------------------------ ---------- ------------- - ---------------------------------------- ---------- ---------------------------- ------------------- FINAL INSPECTION BY:------ ------- Date--- .. 3, ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132,Sycarnore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21A 14%446 ATWDCD 12-S4 T