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o ' APPLICATION FOR SANITATION PERMIT � Permit No. f�w (Complete in Duplicate) Date Issued ---------- Application Application 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 o. 54 9., JOB ADDRESS A LO TIO -- ---- ..................................... -------------------- -•------------ ---- - , .-/V Owners Name__ 1'__f - ----, ••-- -- ;-k----- --------- --------------- - --------- - -------------------- Phone_- " ------ ------- Address------LF ------Address------LF 6 - ----------- ------ -- ------ ----------------------------------------------------------------------.-_----------------------=--------------------- t Contractor's Name---- ------ ----- ---------------------------------------------------------------------------------------------------•-- --.Phone--------------- ------ Installation will serve: Residenc�ef, Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot?l ❑ Other Number of living units: _V___ umber of bedrooms _Z__ Number of baths ___L___ Lot size ___lam,o--- _ _ _ _______________________ Wafer Supply: Public system [Community system '❑ Private ❑ Depth to Water Table ______ ft. VNew Gravel Sand Loam Clay Loam Clay ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: S ❑ y ❑ Y ❑ Y Previous Application Made: Yes ❑ No Construction: Yes L IVO ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Yank- Distance from nearest well_____ _________C}istanc,,��jj from found ti Septic -------- Mate ri i�_________-___________ ___ _. - -____. +' ). No. of compartments------------ ---------Size----�f-_X __X _Liquid�de th---------_---------------Capacity-•--- Q: --- Dispos Field: Distance from nearest well __------Distance from foundaf n___t________ Distance to nearest lot lin _7I_-___________ Number of lines____________ ___, _____ Length of each line___-�___° __.Width of trench_______h��1=-______-_--__---_ ll Type of fitter mate rial _c _! 9E'# epth of filter material-------!_. _____._-Total length-------J_e _ -----------:---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation----------------...Distance to nearest lot line-_",-____------- Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------______-____. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid CapacitY----------------------------gals.';`a Privy: Distance from nearest well ____------------------------------------------__Distance from nearest building___________-____________________-_------ i ❑ Distance to nearest lot line------------------------------------------------ --------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------•-------------•---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------•--------------------------=------------ 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. s 1 (Signed--�'r_-•t-• --�---------�-- ---- --------------------------------- -- ----------------------------- -----------------=------(Owner and/or Contractor) By:------------- ---------------------------------------------------------------------------------------------------------------(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 APPLICATION ACCEPTED BY--- ----------------------------------------------------------------------- DATE----- w REVIEWED BY------------------------------ ---------------------------------------------------------------------- DATE = ------------------------- ----- --- -- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------•--• ----------------------------------- Alterationsand/or recommendations---------- ------------------------------------------------------------------------------------------ ----------------------------------------------•---------- ----------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- F ` ------------------------------------------------'---------------------------------------------------------------------•----------------------------------------------------- - --- - f -------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------••- -----------------------------------------•--- 111111 �/1f- 1 f- 11_. j FINAL INSPECTION BY---------------- -----Y__--- --------------- Date---------------�i_1-_.-- qi - --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r 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 B-51 Revised W-2100 t