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l r APPLICATION FOR SANITATION PERMIT Permit No. ._.33._ (Complete in Duplicate) ` Date Issued - - --._- � Application is hereby made to the San Joaquin Loca! Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5 9. -7 S JOB ADDRESS AND LOCATION-____- -- -- -3_- -.-- - - ----------- Owner's Name r - ----------------------- Phone----- -----------------_ ---------- Contractor's Name--------------•---•---•_--•-- Phone--- p ❑ ��9 Installation will serve: Residence , Apartment House Commercial ❑ . Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J---- Number of bedrooms - Number of baths J---- Lot size --- 4_"__ _•L_[. __r-------------------- Water __----_ _ -- Water Supply: Public system)?q.,Comm unity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe- ' Hardpan ❑ Previous Application Made: Yes ❑ No,;F!�_ New Construction: Yes ❑ No ❑j TYPE OF INSTALLATION AND SPECIFICATIONS: —septic tank or cesspool permitted if public sewer is available within 200 feet.) VLNo n rnce from nearest well__iYs�w-.Distance from foundation_ --r ------------ t real F- � No. of compartments--------- ---------------Size- �fi - /_.Liquid depth--._- - -_� f------------CapacityB ��,V1T � - D Disposal Field: Distance from nearest well-_ fh Distance from foundati n-_,'i°___-_.-_.Distance to nearest lot line------s�i_:` I Number of lines---•_-'--� ' Length of each line--- -Q'-----------Width of trench_..0_44j'----------- - ------- g Type of filter material__f�s� _---Depth of filter material_---- /_ w _ -"---_Tofial length--, '---------------------------------- Distance ____O--'---- - - ----------------•- seepage Pit: Distance tolnearest well----------------------Distance from foundation--------------------Distance to nearest lot line __----..---__-._- ❑ Number of€pits----------------------Lining material---------------------- Size: Diameter------------------ ----Depth------------- Cesspool: z Distance from nearest well-- ---------------Distance from-foundafion----_-__----._-___-.Lining material_-_-----_-.------___.___-__ M --------- ❑ Size: Diameter Depth----•-"-•------=-- -- A `---------.-Li Liquid Capacity _,�_.... ,..,.�_ - �-------iq ------------- --------------gals. Privy: Distance from nearest v✓ell_______________ ---- _ ----___._Distance from nearest building-------------- ❑ Distance to nearest lot line------____-._--_. =" Remodeling and/or repairing (describe):----------------------------------------------- t ---------------------------------------- --------------------------------------------------------------•--------------------------------------------------------------------•------------------------------------------------------------------------------- I I hereby cerfih that I have prepared this application and that the work will be done in accordance•with San Joaquin County ordinances, State a s; and ru s and regulations of the San Joaquin Local Health District. {Signed)______-__-_- - ------ji�n � Contractor] By. - -- (Title) ._ ----------------- (Plot plan, showing size of lot, location of relation to ells, bu ildings, etc., can be placed on.reverse side). FOR DEPARTMENT USE ONLY 1, APPLICATION ACCEPTED Bl ---------- DATE--. --------------------------------------------------- REVIEWED BY-.. __- -------------------- - --------------------------------------------------- DATE__(.�- BUILDING PERMIT ISSUED----------•------------- - DATE Alterations and/or recommendations------------------_-_-.--__--_..._._ ---------------------------------------------------------- FINAL - ------------------------------------------ FINAL INSPECTION BY-------- ----- - ---�c.__-- __--- '` = Date-------- J ------------------------------------------ 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 ES-9-2M 10-52 Revised W-2100