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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / Date Issued --- Application is hereby made to the San Joaquin Local Health Di frict f a permit to construct and install the work herein described. This application is made in compliance with County Or finance 1 JOB ADDRESS AND LOCATI N----- - A/o __ -- � f,�f ---------------- - -----v�------ham`------ - - Owner's Name __--.- r ---�=--.- ----•--- - - - - t - Phone---•------••-------------•---- --- Address 1 ------ ---------------------------------------•-------------._... Contractor's Name---_-- --_ —Lr. -- ----- ---------------- - - ---------------------------------__---------------- Phone-------•---•-------------•----- Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j----- Number of bedrooms --A--Number of baths I----- Lot size ---------Gjo----- �--f-��------------• ------ Water Supply: Public system IN Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2( Hardpan ❑ Previous Application Made: Yes ❑ No 6 New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)I Septic Tank: Distance from nearest well_-/Y�nC,, Distance from foundation- /� � � Material �� ""`'� No. of compartments----- --------.-.Size. '�� X ----Liquid depth--- Capacity Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of lines-----------------------------------Length of each line----------------------------- Width of trench---------------------------- ype or filter material------- -----------------Depth of filter material ---.--------..--------Total length------------------------------------------ Seepage __----..----- _-__--_Seepage Pit: Distance to nearest well.--lfje-}�I- -Distance from fa ndo ion-__/-_�--._-.-.Distanp to nearest lot line--__-4~----_ Number of pits....../------------Lining material---Com✓-C e: Diameter----- _--.----Depth.-. - ------------ Cesspool: Distance from nearest well-----------------Distance from foundation................... Lining material-----.--------.----------_------_----. ❑ Size: Diameter------- -------------- ----------Depth-------------- ------------ ------------------- ----Li Liquid Capacity-. .- q p �-"--------------------------gals. Privy: Distance from nearest well----- I -------------------- ---- -------------Distance from nearest building------------------------------ . Distance to nearest lot line_-_----___.--..--._ Remodeling and/or repairing (describe)------------------------------------------------------- N ----------------------•---------------------- -----------•----------------------------------------,:- -------------------•---------------------•----------------•--------•------------------------•------------------------------------------....- ---------------- ---------------•------•---------------------••-------------•----------- ---------------•--------••--•--------•-------------------------------•-----•-------•-----------------•---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County yk ordinances, St7_�:Z S. and rules and regulations of the San Joaquin Local Health District. (Signed) ... - ----••-------- -- -- / Contractor) - - - Ow er and ora By:.-.. ----- ---------------------------------- Title------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ - ---- --- ---- DATE-- -- -- ------------------------------------------- - ------------------------------------------ REVIEWED BY - -- - -- DATE ------- - - --------------------------------------------------- BUILDING PERMIT ISSUED--------------- ------ ---------- -- DATE.- ------------- ---- Alterations and/or recommendations:._ ----------- --_.--- - `4- ------------__----------- ---...------ - --------••------------------------------------•-------•-------------- ----------- .... ----------------------•-- - - -•----- -----....... - --------------------•-------- ---------------------------------------------------- ------------------------------------------------------------ ------------- ------------ --- -- --- - ----------------------- -------------------- ---- - FINAL INSPECTION BY:._-- �-,----• Date r � -1 -- � � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOnO 12-54