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Permit No. APPLICATION FOR SANITATION PERMIT f r3 0 1 (Complete in Duplicate) Date Issued __ �� 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 N;�4 4 JOB ADDRESS AND LO ATION------- �� =- ----- ----------------------------------------- �Cl ----- -------------------------- ------- Phone------------------------------------ Owner's Name- -----_G�_ _ ��-- -------------------------------- - Address----------- ------------- Contractor's Name---------------- -• ------p- - •- - - -------- -- f Phone 1 Installation will serve: Residence g� r` artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E] Number of living units: j___ Number of bedrooms --.::?—Number of baths _l___ Lot size ,�Q--_ �_ - -- -------------------------- Water Supply: Public system P--Iccmmunity system ❑ Private ❑ Depth to Water Table -;KA if. Character of soil fo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E �Hardpan ❑ Previous Application Made: Yes ❑ No Y�,'New Construction: Yes R4---IVo ❑ . FHA/VA: Yes 33-�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ' Material... �� -----" Septic Ta k: Distance from nearest well 'Distance rom foundation___�,�_____. ,V No. of compartments----�--- -----------------Size_tf�_X VAO ---_Liquid depth---�V___�-------------Capacity--c�a'� - j ' Disposal Field: Distance from nearest well_. �bistance from --------Distance to nearest lot lir`r_ -.___. Number of lines:!___ _______ Length of each line____ t,4-740/---------- of trench_-___Avg_________________ 1 De th of filter material- Seepage Pit: Distance to nearest well_. _"Distance f;om fo�dation__4--___.__.Dista�v to nearest lot line_ -.--------- {---� Linin material_/� ---.Size: Diamefer---J%?-----------Depth---- p -- Number of pits g � i it Cesspool: Distance from nearest well_____-_________-Distance from foundation__________________.Lining material_.___________________-_________-__-. l El Size: Diameter------------------ --Depth----------------------------------------------------Liquid Capacity----------------------- gals. Privy: Distance from nearest well---------------_---------------------------------Distance from nearest building----------------------------------------- Distance . ❑ to nearef st lot line ------------- - --------- ------------ ------------------•------..-------•----------------------- Remodeling and/or repairing (describe):----------------- --- -' - ----------- ---- ------ t7 ------------------------------------------------ ►- - --- - --- - ---------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Counfy ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. i� { ontract (Signed) -------------- Title ' ---------------------------- __ _ { , ). t (Plot plan, showing size of lot, locafi of systerrm.in relation to wells, .buildings, etc., can.be placed on reve side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•- -------------- ---�- -- ------- -- "------------ ----------------- DATE -r-- - -�------- ------------------ ------ DATE---------- --------------------------------------- REVIEWED BY---- -------------------------------- BUILDINGPERMIT ISSUED------------------------------------------ -- --- ----------------------------------------------- DATE--------- - --------------------------------------------- Alterations and/or recommendations:---------- ----- ----------------------------- -------------------------------------------------- =� �' ZL ---40e .-�-fuJ--------------------------------------------•---------•-------------- ---------------- ------------ - ------- --- ------ - ------------------------------------------ °�- ------------ FINAL INSPECTION BY:_____--- Date `'' V ------ SAN JOAQUIN LOCAL HEALTH DISTRICT cirnora Street 130 South American Street 300 West Oak Street 132 S� Y ..814 North "C" Street Stockton, California Lodi, California Manteca, Colifornis Tracy, California ES-9-2K4 Revisea 1-57 F.P CO.