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`a I� APPLICATION FOR SANITATION PERMIT Permit No. ________________-- (Complete in Duplicate) 0 Date Issued - - ----- - Application is hereby made to the',San Joaquin Local Health District for a permit to ccnstr and install the work herein described. p p p• n with County Or 'nance o. f (�( �@ JOB application � Is D LOCATION- - -- ----- --------- ----------------- -I-�-�"�'"'-'-�----- ------1�---- --- --------- -/--------------------------�----------- - --J �a (done- Address � f Owner's me---e--- ----••- ------------- ------ - ------- ----- ---------------------------------------------------._ (done= Address--�--Q------ - -----� --------- -- ---- -- --`-------------------------------------------------- ---------------------------- - Contractor's Name--------- -------- --------- ---- I- ----------------------------------------------- -------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 'pp� I 11 Number of living units: Z Number of bedrooms ---ZA Numbetwh maths _�__ Lot size _-_�__e__�--I _Q- _------------- __________ I Water Supply: Publics stem Community system Private to.Water Table �_o ft.PP Y� Y ❑ Y Y ❑ _ Character of soil to a depth of 3 feet: Sand Gravel El Sandy Lolay Loam E] Clay ❑ Adobe Hardpan E]L_+ I Previous Application Made: Yes No New Construction: Yes ;"NoE1 TYPE OF INSTALLATION AND SPECIFICATIONS: , `Se tic (No P - Distance from'permitted if pu lit s�wer is available within 200 fget,� f� p No se tic tank or cesspool nearest well___ V____Distan fro our) lull------- i No. of compartments-------------- ---------Size-- -�-r�X_�__Liquid depth----------�..---------Capacity--1 2;5_Q------- Disposal -----_Disposal Field: Distance from (nearest well------------------Distance from foundation--------------------Disfanceto nearest lot line_________________ (] Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material____________________ Depth of filter material ______------- - Total length____________-_-___________________ Seepa Pit: Distance to nearest w I{___�_��_!/-------Distant rem fo dation__:__ _______.Dis ace.#o nearest lot lin _ QNumber of pits---------- ---------Lining material- -----_---- ------- ize: Diameter------ -_---------Depth-",--,-.J- ---------------- Cesspool: Distance froml�nearest well----------------- from foundation--------------------Lining material______________________________ FSize: Diameter________________ ___ _De th-----------------------------------------------------Liuid Capacity ______ __gals.� F...rs�+i.--�..=c�a�=+:7.�`:•-'w�_,.T'.,--�_��'.- �'.�-_�.�.�::a.r_y_. _� ..e..,,,.�� _.—.;. � ._.. .._.��, v�:�_ � �_�-.___�-.�_ _.�...r� _- Privy: Distance from nearest well____--- -----------------------------------------Distance from nearest buiiding----------------------------------------- Distance ____________________________ _Distance to nearest lot line --------------- ----- ---------- -- ------- --- ---------------------------------------- --- Roming 'nd/or` repairin (d -------------------------------- --b ------------------•--------------------------- :------= '' - f --------------------------------- ---------- ordinances, State laws�and rules e - ,.�_ ._ --- ---------- - --------- ! h reb ertif that I have prepared this applica i n and that the work will be lone in accordance with San Joaquin County nd regulations of San Joaquin Local Health District. (SignSi ned r� - -------------------------------(Owner and/or Contractor] ed) ------- -- _ -------------------- r.By:--------_------------cliif - -- ---------•-------------------------------------------------=---------- -----(Title)--=- -----------------------=- = --------------- (Plot plan, showing size lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 11 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------- --------------------------------------------------- DATES r REVIEWED BY ---------- - - DATE_ �� BUILDINGPERMIT ISSUED------- - -= ------------------------------------------------------------------------------ DATE------=-V,��--------------------------------------------•- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------_;",--------------------------------------------- ---------------------------------------------------------- ------------------------------------- ---------------------------------------------'----- ----------------------------------------------------------------------------------------------------------------------------------- il __ ----------------------------------------------------------- ----------------------------------------------------------------------------------------------------------•----------------------_-----•-------------------------- -------------------------------------------------- --------------------------------------- - -------- ---------------------- ------- FINAL -- -------------------------------------------- -- - - -- -- /--� FINAL INSPECTION ------ Date - - ---------------------- ------------------- 1 SAN JOAQUIN LOCAL EALTH DISTRICT I , f } 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street I' Stockton, California ` Lodi, California Manteca, California Tracy, California ES-9--2M 8-51 Revised W-2100 f