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APPLICATION FOR SANITATION PERMIT Perini+.l,*lo- . Y b {Complete in Duplicate) - Y l Date Issued y '/------ �� _206— 0 Application is hereby made to the San Joaquin Local Healt District for a permit to construct and install the work herein described. .aThis..a plication.is made,in compli rice witb County rdinance No. 54% i� � . .�.-•`�•�rr�A-L. motif JOB 'AD DRESS AND: LQCAT I "` "" -' (/ -------------------------------------------P- -h--o--n--e----------------------------- hone---------- ------------Owner's Name , r`' ' , { ----- ------- ------ `i Address------.... --------------------------------------•-•------------•-------------- ....._. Contractor's Name----- ------- ---------- ----•------ ---•--------------------------------------------------------------------------------------------•--- Phone----------------------------------- Installation will serve: Residence V partment House ❑ Commercial ❑ Trailer Court ❑/ Motel E] Othee Number of living units: __�___ Number of bedrooms --- _ Number of baths --I____ Lot size __L�_Lf-___�._�_: .(L��__ --------------- k Water Supply: Public system ®Community system ❑ Private ❑ Depth to Water Table -------- ft. f- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;?'No Clay Loam ❑ Clay El Adobe Previous Application Made: Yes El No l-2 New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ubliF sewers available within 200 fees) Septic Tank: Distance from nearest well � Distanc fr fou ation/________________Mater'al!___.____._.______...___.__,__- ❑ No.: of compartments--------- --_-_i._-__5,ize_�x _ __ _--Liquid depth------ -�-----------Capacity____25- - r°.- Dispos 1 Fle1d. Distance from nearest weliz istance from foundation___!_V: tante to nearest lot line_______________ _ Number of lines__________ __ ____ Length of each line_ rp �v -_-- ____ __:�__..Width of trench-. --------- -------------- + j� rf Type of filter material________ _ ___________Depth of filter matenaL____:�- t?_... length-------.__._...-� ---------.--------- -�+ Seepage Pit: Distance to nearest well-.__________________Distance from foundation_______..___....___.Distance to nearest lot line----------------- [__1 Number of pits----------------------lining material-----------------------Size: Diameter-----------------------Depth------------------------------VZ+ i Cesspool: Distance from nearest well-----------------Distance from foundation_:_:--_'__.._----.Lining material-...___----------------------- ------1 ❑ Size: Diameter--------------------------------------Depth--------------------------------- --------------- --Liquid Capacity- - ------------------------gals, ❑ t -----------=------------------------g------------------------------------------ �' Priv Distance rom nearest well___.---_----------------------------------------Distance from nearest buildin } Distance to nearest lot line--------------------------------------------------- -- --- �^"47, ode'ng and/or repaif.ng (descr b.e).'----------------------------------------------------------------------------------------------- -------------------•----------------.,. l7`1 ------ --------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------�'�1__ �------{ l_---- _ / ---------------- (Owner and/or Contractor) $ {TitleJ_ Y• -------------------- -------------------------------------------------------------- (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 recommenda.fions:------- --------------------------------------------------------------.....-------..--------------•------------------------------------------------.------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•------------------------------------------------ ----------------------------------------------•----------- -- ----------- --- -------- --------- --------------------------------------------------------------------------- ------------------------------------------ ----------------------------------------------------------------------•------- ------ ------ - - ------------- •-------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------- ---------------------------------------•- ------ ----- Date------------------------ ------------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streof 300 West Oak Street 132 Sycamore Street 814 North "G" Street Stockton, California Lodi, California Manteca, California Tracy, California LS-9-2M 10-52 Revised W-2100