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APPLICATION FOR SANITATION PERMIT Permit ao,3--------------------- / z, / (Complete in Duplicate) p Date Issued A plication is hereby made to•the Son Joaquin Local Health District for a permit to cons ruct andstal ��w rk herein described. This application is made in compliance with County din No. 549. / 4 JOB ADDRESS D LO . 101!"-_. ------ ------ - -- ( _ - ------------ ------ Phone- 9 q-a Owner's Name----V--------------- ---- •- --- Address.._----------1� - ----• ------ ---c----------------------- ------------- - -----•-•----- --- --•----------—-- ---••-- Contractor's Name------------ �--------------- ---- ----- -----.---------------------------- Phone.,-------� --------_-_ - . Installation will serve: Residence ;Apartment House ❑ Commercial ❑ Trailer Court ❑ tel ❑ O h rp Number of living uriits: ._-/__._ Number of bedrooms -- Number f baths ---- I __ Lot size __9- X_ .z- -------•-------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __ ____ ft. Gravel Sand Lo;/No Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Character of soil to a depth of 3 feet. Sand ❑ y Y l ,Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No,septic tank or cesspool permitted if pu lic sewer is available within 200 feet.) I Septic ank: Distance from nearest well____ ___ __:Distance fro fou ation___1_________.___.Mater a�__ __- ___�pT , f'i"- ---------Caacit No. of compartments------------ Liquid Beth- - Y /� M1 ' Dispos 'I Field: Distance from nearest w ll____�-.L! -_`Distance from foundation __-__-____--Distance to nearest lot i 41 Number of lines---------- ------__ ------ _4 Length of each line-------- ._ _ -- rF----Width of french - - Type bf filter mater ____ _��Depth of filter material_-_.-___.I_ ------Total length---------_1__ _0___________________ t Seepage Pit: Distance to nearest well---------------------'Distance from foundation----------------.__.Distance to nearest lot line----------------- 0 Number of pits -Lining material -----------Size: Diameter Depth Cesspool: Distance from„nearest well______________�Distance from foundation------------------- Lining material----------.-__-_____-________-__--_-. ❑ Size: Diameter-------------- ----------------------Depth---------------------=---------- ------------------Liquid Capacity----------------------------gals.. Privy: Distance from nearest well------------.-------------------------------------Distance from nearest building-------------------------------------.---. Distanceio nearest lodline----------------------------------------------------------------------------- -------------------------------------------------------------- Remodeling and/or repairing (describe):__._---”-�-------------------------------------- --•----------------------•----------------------------------------------------------------------------- ----------------------------•--------------------------------•••----------- ------• ----------•-•---------•----------- f ..__________.________....-_..________ ___________________________________________________________________i__._______ ____________---._____________________ __________ _-----------_-------_---------------------___________±__________�_-------_-----------------------------------------------------------------------------------------------------_ _--__-______-___-_- .....- I hereby certify that I have prepared this,application and that the work will be done in accordance with San Joaquin County ordinances, St laws, arid. vales and r •letions of the Ss, Joaquin Local Health District: (Signed)------ ---- ---- ---- --- ------------------------------------------------------------------(Owner and/or Contractor) s_ _ � - - ------------------_.,.- -Tit e)----------------- -- ----------------------- ---------- (plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY- APPLICATION ACCEPTED BY } DATE_ ---------------- { REVIEWED BY---------------------------------- t----=------------------------------- - ------------------------------ DATE---f_---------------------------------------------- BUILDINGPERMIT ISSUED------- ------#-------------------=------------------------------------------------------------ DATE--------R---------------------------------------------- t s Alterations and/or recommendations----------------------------------- ----------------------------- ------------- -------- •--•---------------•---------•-- -------------------------------------------------------------------------------------- --------•---------- ----------------------------------- ---------- .— •_�-- - _- .-. k ------------------�--=-=---•--=-----------------------•- -- ---------------•---- ------ --------- --•----------------- - ----Date-- --------- -- ----- - --- + --------------------------------• FINAL INSPECTION BY:----------------------------- -- �YV4 + 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 t t I l ES--9-2M 10-52 Revised W-2100