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APPLICATION FOR SANITATION PERMIT Permit No. ___ -------------- (Complete in Duplicate) 5� Date Issued ________I______ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance 5 °! l JOB ADDRESS AND OCAT N '--------------------------------------- Owner's Name . ------ Phone -- ------- -- --• •• - Address - ------ ----------------------------- . --- --f .. -- -- ` e p Contractor's Name l.Ld" /__L_ "i_:4 � = - `� -•----------- ---------------- Phon Installation will serve: Residence ar ment House ❑ Commercial E] Trailer Court E] Motel [3 Other ❑ Number of I.iving units: /-"-_ Number of bedrooms __,b. um .�ber of baths ___I___ Lot size .--- ----- (,7_____________. � •Water Supply: Public system y system ❑ Private 21 Beeth to Water Table(_5 ft. Character of soil to.a{depth of 3 feet:-,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe berdpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes" ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet) If 19 Septic Tank: Distance from nearest well_/ _.___Distance from foundation""" ---------Materiai____ ._�________________" _____:_______- �c, No. of com artmenis_ ' ' ----------Size:i-- d_.._..Li Liquid de th______ p �-�- -" �--A�--- q P �'-t-----------Capacity.- -s.S_61. ---- Disposal Field: Distance from nearest we31.1��_'._,Distance from foundation___ a_-r.._..Distance to nearest lot line.+------ P � Number of lines------- al of each line____ P--- _��__._.Width of trench.__ __�_�________________ yp - �_ ---_-- Depth of filter material_____f, tom, T e of filter material_-- __-. .---_--:-Total length----.-s.,y_-0------------------------ IF �, - --_- __Linin material_- w- size: Diameter"_11 -----"-_---De th--- lot line --_ti --------- Seepage - Pit: Distance of Pts re 1r+well_ .�g Distance om fou ation-_"______ ____.Dis ante to nearest 4 Cesspool: Distance-from nea-rrest-well----_----------___Distance from foundation--------------------Lining material-------------------._________________- ❑ Size- Diameter------------------ ------------ ------Depth--------------------•-•-----------------------------Liquid Capacity- ------------------- ------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_--.--___.__.________________.__..______- ❑ Distance to nearest lot line- .. - s *; Remodelingand/or repairing (describe):--..--R----------------------------------------------------.-------------------------------------------------------- •---•-------------------------- ------------------------------------ -----------------------------•------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta. ws, nd rujal and re uia+ions of the San Joaquin Local Health District. :. (Signed)------`------- -- "' --------(Owner and/or Contractor) B • ... ---------ry-- --�"' —=`----------------------"-----------------------------------(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 4 APPLICATION ACCEPTED BY---- ----------- --- - --- "----------- -------------------------....--------- DATE--------- ----- REVIEWEDBY-------------------------------- ----------- y'-++.--- ---------------------------------------------- DATE------ -- BUILDING PERMIT ISSUED----------------------------- -- .--------- •----------------------------- DATE = -1---�c Alterations and/or recommendations .---.. ---------------------•-------------------------••-------•---•---- ----V.• -• -------------------•---------- - --------------•--------------------- "---------------------- ----------------------- --------------------- -•-------------•-------------------------------•-•---•-------- r ! - FINALINSPECTION BY:----. �_ ----- --------------- "--- Date----.- .----�'--- -"`------------------------------------------ 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 . rZ- V-2M --6 ATH/ i2-Sa