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' b APPLICATION FOR SANITATION PERMIT Perm-it \" (Complete in Duplicate) 3 a1P� f Date Issued ___. ___��3__. pplication 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 N C� 'Y` r JOB ADDRESS AND LO TION____ �.__�� _ '- '�� -_ Owners Name--------------------- -� r1N-�� ------- Phone ------------------------------------- Address... •----------- ... ` � � �r 0 Contractor's Name = :� �d �1 Phone K0 Installation will serve: Residence T Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other I Number of living units: bedrooms _ _ Number of baths .!____•Lot size - .� __ l_.�__ ___------------------- Water Supply: Public`-system Community system ❑' Private E] Depth to Water Tabl�Xd ft. Character of soil to a depth of 3 fee+: Sand ❑ ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe- Hardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes Imo' 1VO ❑❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted,ifzpublic sewer-i!available-within :200 feet.) Septic Tank:,. r Distance from nearest welf--------;,_ A-_Distance from foundation__F______________.Material-_-_->_________________..__________- - -- 7 2os 9alf tomNo. of compartments--------•�-�--/---------- ize-------- --------------:-'-Liquid dpth--------------------------Capacity..------------- - ---- Dispield: Distance from Weare t elY__r_d�-4/Di stance fro''m foundation_�L1----------Distance to nearest lot line____-___ Numr or' lines_______ ____ __ _ Length of h line Z1_° , 5'!Width of trench____ � r Type of filter mr eachaterial-._. - _ ._Depth of filter material-__ s : _l_______Total length-----1__ __ ------------------------- Seepage Pit: Distance to nearest well._-__+_____________Distance-from foundation______'_:-______-_.Distance to nearest lot line------- ❑ Number of.pits--------__''>------__Lining material-----------------------Size: Diameter-------------------.___Depth--------------------------------- Cesspool. Distance from nearest well-----------------Distance from foundation------------------- material______.-.._._-_.______._______-_---__ ❑ Size: Diameter------- -------------------------- ---Depth-------------------------------------------- - -----Liquid Capacity----------------------------gals. Privy: Distance from nearest,well-------_---------------_---------------------____Distance from •nearest building-----------------------------------------. ❑ Distance to nearest lot lire------------------------------ -------- ------------l---t---- ---- ------ =; Remodeling and/or repairing [describe]: ------- -- --------------------- ------ -----------•---- = _ ------ . -.- ------------------------------------------------------------- i -------------------------------------- -------------•--------= -------- -- ------•------ ---------------------------------------- --------------------------------------------------------------------------------------------------•---•-------- ------------------------•-------•----•----------------------------------- I hereby certify that I have phepared,+his application and that the work will be done in accordance with San Joaquin County ordinances, State laws,`and rules and.regulations of +heiSan Joaquin Local Health District. (Signed) - -------------------------------------------------------------------- •------------------.(Owner and/or Contractor) L , By:----------------------------------------------------x.----. --------------------- '---------------------------------------------Fit le)-------------------------------------------- ------------------ (Plot plan, showing size of lot, location ofjsystem in rela+ion +o"wells;' uildings,"etc.;can he:placed on reverse side). I FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY DATE_. ��+ 3 f REVIEWEDBY ------ -------------- ---------------------------------------------------------------------------- DATE ------------- BUILDING ---- ------BUILDING PERMIT ISSUED--------------------------------------------------------------------------- ------------------------ DATE-------•-------------- - -- ------------------------- Alterations and/or recommenda+ions: _- - --_ - m --------------e----f---------------V.-::------- -- ----••- • ---- -------------- r --- -� `� o-I( � lad IT, t S A �� -I,----- ✓�� -----�- --C-c-tri '� ..S:d ------------=--------=----=---------------------------------------------------- --------- ------------------------------------ ---------------------•--- -------- ------------------------------------.-.__--.--------------------------------------------•--------------------------------------•--•---------- Y�y--- FINAL INSPECTION BY:.......fes----- � ----------------------- Date " "�----------- SAN JOAQUIN LOCAL.HEALTH DISTRICT 130 South Ari erican Street 300 West Oak Streat 132 Sycamore Street 814 North "C" $tree+ i Stockton, California Lodi, California Manteca, California Tracy, California € ES-9-2M 10-52 Revised W-2100