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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date 1'5 ued ----- -7 A by made to the San Joaquin This is here Local Health District for a permit to construct and install the work herein described. 's application is made in with w�compliance ith ourify Ordinance No w JOB ADDRESS AND LO --- y---`'�---767----- ------ Owner's Name- —- ----------- ---------------------- ------------- Phone------------------------------------ ----------------- --------- C A/ s,� Address------------------------------------------- AMC --------------------- r Contractor's Name-------------------------------------- ---------------- -------ak--------------------------------------- Installation will serve: Residence X Apartment House F1 Commercial F] Trailer Court Ej Motel. [-1, Other E] Number of living units: -1---__ Number of bedrooms Number of baths _1---- Lot size Water Supply: Public system Community system F] Private Ej Depth to Wafer Table 4Z_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E-] Clay Loam E] Clay El Adobe, Hnr,4,ui. Previous Application Made: Yes El No 9 New Construction: Yes [:] No A FHA/VA; Yes E] NoN TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_---------------Distance from foundation--------------------Materiai------------------------------------------------ E167%ft?1/A/4 No. of comparfments-------------------- -----Size--------------------------------Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest we1l_A)6.C:_D iStance from foundation---- a__f /A _-_-.Distance to nearest lot line-.2 -------- Number of lines----- ----------Length of each line---- ------ -------Width of french_�r,:W ------------------- Type of filter material__,`� --Depth of filter material--- ---------Total length__-.___- �_/_p------------------------ ( A Se e Pit: Distance to nearest well-WAVIVE-_Distance fromef sja+ion___—V_ '*.-------Disfarice to nearest lot line - --- ------------ Number of pifs_&�___ -------.� Lining material-R----------------S;ze: Diameter-----3,3"'r D e p f h I---------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------M----LLining material--- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-------------------- 92 Privy: Distance from nearest well------------------r--------------------------- -Distance from nearest El building--_____---------- Di�tance to nearest lot iine -------------- ------------------- --------------------- ------------------------------------------------------------------------------------------------ --------- Remodeling and/or repairing (describe):-- ------ ----------------------------------------------*------------------------ ---- ------------ ------a --------------------------------------------1, -------------- ---------------- --------------------------------------------------------------------------------------------------------------------I----------------------------- ------------------------------------------------------?_- ----- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------r-------------- I hereby certify that I hav r a red this ap�'plication and that the work will be done in accordance with San Joaquin'County ordinances,•State laws, and es b I regulat,of the San Joaquin Local Health District. Al (Signed)------------------ ------------ ----- Q24/---6 --------- -----------2Owner and dor Contractor) ------ --- ------- By:------------------------------------------------- -- (Title] i----- ?n -----�io ----------- (Plot plan, showing size of lot, locatio o system in relation to wells ------ buildings, efc., can be place on reverse side). X FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- k_R_k_0 ------------------------ DATE------11 REVIEWED ATE------REVIEWED BY7------------------------ BUILDING PERMIT ISSUED ----------------------------------------------------------- DATE-------------- ---------------- ------------------------------------------------- DATE Alterations and/or recommendaf ions:------------------------- ----------------------------------------------------------------- ------------------- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------- -------------------------------------------------------- ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------------------•-------- FINAL INSPECTION BY:----- --------- - ---------- Date------ -Z J- --------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreaf 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-11-2M - Revisea 1-57 F-P-CO-