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APPLICATION FOR SANITATION PERMIT Permit No. _____y (Complete in Duplicate) _ Date Issued ---- ��41 a 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 00, ,� 4 . r JOB ADDRESS AND.L0CATION____ ��_ �y ---- Owner's Name----- •-�.r- -- �st� _ -- / f y =" Address.. -�® V'"" ; Phone Contractor's Name -' ---- C ----------------------- Phone ---------------- - Installation will serve: Residence UWApartmenf house 0 Commercial t Trailer Court ❑ Other ❑ ❑ ❑ Mitel Number of living units: _�: Number of bedrooms _��_ Number of baths __ __ Lot size _ _iC-- --- J• -'"' . ? "I Water Supply: Public system Community system ❑"' Private ❑ Depth to;Waiter Table Character of soil to a-depth of 3 feet: Sand ❑ Gravei ❑ Sandy Loam ❑ Clay Loam ❑ 'Clay ❑ AdobeR-_'Hardpan ❑ ° Previous"Application Made: Yes ❑ No New Construction: Yes ❑ No W?' FHA/VA: Yes P�'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: F ) (No septic tank or'cesspool permitted if public sewer is available within° 200 feet.) , . Septic Tank: Distance from nearest wel_ &_4.-"Distance from foundation____40 _ No. of compartments_____z __________________Size__4-4P--AC-4(Q_.'_Liquid depth__--- '� � Capacity.... 1 --- ------ p Y-•-- °�- ------ IF Dis osaI field: Distance from nearest weiL___'s Distance from foundation___ j _____.____.Distance�to nearest lot Number of lines____ ___'___________________ Len th of each line_ !i 9 r�1P_---•-- :-----.Width of trench.__ "�----- --- ------ Type of filter material__„ pepth of filter materia!___. --_- � ------Total length------ --�_�---- ------=------•-•-- Seepage Pit: Distance to nearest well_"'__- 71_'Distance'from fo dation____ f �___.D Lance- to nearest lot�linef- Number of pits -.__� '"___.__--Lining matertal,�Air. -Size: Diameter___- -.--____-_,Depth___--.,� .--_--___---.-_---_ ,� Cesspool: Distance,from nearest well________________Distance-from foundation--------------------Lining 1material--------._----.____________-______._. O ❑ Size. Diameter:1=------------- --------_---- ----Depth-----=---------------------------- Liquid Capacity -------gals. Privy: Y Distance from rarest well----------------.------------------------- ------Distance from nearest building--------------------- ° ❑ Distance to nearest lot line I----------- ------------------------------ ', --------------- ' Remodeling enc!/oryrepairing (describe)=-------------- - - -, a - --. -_---------, ---------------- ------.----- -- - --- - = --------------•------------,•---- T t __________u___________ _______________________ __________ f __________________________________________________________________________________________________________________ , _____________________________________7_______________________________ -______.---------------------------------------------------------------- --------------------------------------------------------------------------------- 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 re ulations of the San Joaquin Local Health District. Si ned ( g ) Y: --------------------- B ------ 4 tract - ad�G.ar Con f-or) -- - ----------------•-------------------------------------(Title-- - (Plot plan, showing size of lot,ivcation.of system in relation to wells, buildings, etc., can be paced on revilFirse i ' FOR DEPARTMENT,USE ONLY i APPLICATION ACCEPTED BY :---------------------------- ------------------------------------------------ . DATE_ -- --- ---- -------------•--------------------- REVIEWED BY--- BUILDING PERMIT ISSUED------------------ --------------- - ---------------- ----- DATE---__-------------•----------- � ---- ---- -- -- ------- ----------- Alterations ------------ DATE---------- -- and/or recommendations . ----•----- -- - ------------------------------ ---------------------------------------------- - --------------------------------------- ,. • /` c �� !V.__�_-�-•: .' ?'�.J - " ---------------------- ------------------------------------ - FINAL INSPECTION-BY:------ _- : W �j�"-'f�''- f Date - - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street. t ' _ } 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California �` o ,,.``Manteca, CaliforniaN ■ .,Tracy; California ` ES--9-2M Revisea 1-57 F.P,CO.