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APPLICATION FOR SANITATION PERMIT Permit o..r 4 f o (Complete in Duplicate) & Date Issu� .--./----I % Applica+ion is hereby made to the San Joaquin Local Health District fo a permit to construct and i stall the work herein described. This application is made in compliance with C�o)unrtyy Ordinance 5 JOB ADDRESS AND L TION--_.-_---(/ / ,5,,(� Owner's Name------ -----------•--- .-- -- w Address__..__ _ ------ --------------------=------------------ ---------------- !------ -. Phone ------------------- ------ ---��O __Contractor's Name ----•------ •---- on Installation will serve: Residence [Apartment House [I Commercial ❑ Trailer Court E]Motel E]Other E]Number of living units: __/__ Number of bedrooms _A.- Number of baths -_l-- Lot size Water SuPPI . Publics stem Comunity system ❑ Private t ❑ Depth to Water Table �_+.�_�{}, , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [rTlardpan [] Previous Application Made: Yes ❑ No D"New Construction: Yes ElNo Ems' TYPE. OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pt' ank: Distance from nearest well--- -------------- Distance from foundation -------------------- Material No. of compartments----- ------------------- Size -----•---------- ----------- -- --------------- Liquid depth__.-------- --- ---- ---- Capacity-•-------- ------------ Disposal Fi Id: Distance from nearest well_/ -- Distance from foundation___�� 01- S Distance to nearest lot line_--___ ----- Number of lines---- ----- ------Length of each line---0Q'----------------Width of trench. Type of filter mate ria l_SyRl �� _ __--___ Depth of filter materiaL______.-- -_-.-Total length ---- 3d--- _- Seepage Pit: Distance to nearest well QJ_ --Distance from fo' ndation____ -S __..Distance to nearest Io} Gne----------------- Number.' i of pits.__--,/ -____..__.__ Lining material_ _- Size: Diameter___ -3,3 " ----- ---- -------------- Q � Cesspool- Distance from nearest well_________________ Distance from foundation ------------ -__.___ ' �V Lining material _ ❑ Size: Diameter----------- ---------- ---------- --Dept h ----- -_--=------------- �- - - -- -- --- L+quid Capacity----•----------- -- ------ ------------gals. Privy: Distance from nearest well__________________ ______________________________Distance from nearest building ---------------------------------- C�1 Distance to nearest lot�line-._.__---'j ------------------- - Remodeling and/or repairing fdescribe)--------------------- ----------------------------------•-------•-------•-------------------••------•---------•------------------------------------•------•----------------------•--------•------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County F ordinances, She aws, and r es and regul ions of the San Joaquin Local Health District. (Signed)----------- --------- `L ------------------- - --- -- ------------------- -------------- -- ----c---/-----�: - -�------------- - Owner and/or Cantractorj By:. �r 4 -2__!- 4 �----ITitle) w /o_________ ______________ i (Plot plan, showing size of lot, location of system in relation to wells, uildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- -- DATE�--------------------- ------------------------ REVIEWED BY ----------------------- - �----_---- �-�---- --- -- - - - BUlLDlNG PERMIT ISSUED •— - ----- DATE - - DATE---------- ----- ---- ---- ----- --- Alterations and/or recommendations_� ---- -----•-------- - --- __ ------------ ---- _ ---- ----------------------------------------- -- ----. �- •----•- --------------------- FINAL -INSPECTION BY -_J ... --------------- ------------ -------- "Date ... .---------------- �- ------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California Ea -9 146446 ATWCCU