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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _*p r 0 i z /— Cit Date Issued Application is hereby made fie t e�n Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54.9. JOB ADDRESS AND LO ATION------- - ---- --- ----------- ---------------------_-_-- ��yyyy�� Owner's Name---l& -(---- - -- Phone------------------------- • -- --�------------------------ ---- ---------------- ---- -- -- ------------------------------------ Address------- � ---_ ------------------------ Contractor's Name----------- ----------------- --- --------- --------- --------- ------ ----- ---------------------- -------- Phone., � '`a - Installation will serve: Residence [7 Apa tment House ❑ Commercial [-❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __ ... Number of bedrooms _A--- Number of baths _-I---- Lot size ---------------------------------- Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table 4'-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobetl Hardpan ❑ Previous Application Made: Yes ❑ No 4 New Construction: Yes X No ❑ FHA/VA: Yes ❑ No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material--_---..-----_.--._---_----_---------.-------__. ❑ No. of compartments-------------------- -----Size----._-------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____----_----___ ,0 Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----.------------------------------ i Type of filter material------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well 7S-___ . Distance from foundation----r�___._...Distance to nearest lot ® Number of pits----------1----------Lining material------7aC-<----Size: Diameter--yA'A -__---_.Depth....9-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------___--_-._-----.-.-_---.. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance/rom nearest well --.--..,-�---_----------_----------------Distance from nearest building--------------------------------------- ❑ Distance fa nearest lot line--- - ---------------------------------------------------------------- Remodelingand/or"repairing•(describe):------------------------------------------------------------------------------I--------------°° ---_---------------------------------------------------- s ..0 ____________________________________________________________________________________ Y - ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 andrp�u tions of the San Joaquin Local Health District. " ` I (5i ned g } ----------------------- -------------- --------- ------------------------------------------------------------(Owner and/or Contracfor) By:------------ --------------------------------------------------------------------------- -------------------------------------------(Title)-------------------------------------------------------- ------ - (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------t'- `L ----------------------------------- ---------------------------------------- DATE.---- `23 � REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE------------------------------- BUILDING PERMIT ISSUED------------------------------- ---------------------------------------------------------------------- DATE Alterations and/or recommendations!_"------------------------------------------ ------------------------------------------------------------•------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------- ----------------------------------------------------- -----------------------------------------------------------•-------------------------------------- --------------------------------- ---------------------- - ----- -- --- =r l ------------------------------------------------------------------- FINAL INSPECTION BY - - - ----- --- --- Date----- --- - ---- �r�' Z�-- ---------------------------------------- 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 ES-9-2M . Revisea 1.57 F.P.CO.