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APPLICATION FOR SANITATION PERMIT Permit No. - (Complete in Duplicate) / 7 S 3 Date Issued V _7 _ T lication hereby made t j PP y o the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with CountyWO�inance Nos 9. JOB ADDRESS AND LOCATION______�A0 0 ---------------•------------------------------------------------------- ------------------------- -- ----------------------------------- Owner's Name---0�-V-Q__ .4 //r - - - - Phone--------------- -------------------- Address ----------- j Address------------ --j a --------------------------------------------------------••--------••------------------------------- q ----- ---- -------- Contractor's Name----------- ____ - - -. --___ Phone- ............. f`l--P ' 7 _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel L] 10 Other ElNumber of living units: _ Number of bedrooms .. Number of baths __a2r_ Lot size _ � --------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table AA- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Eg-'f4ardpan ❑ Previous Application Made: Yes [] No [ New Construction: Yes ❑ No I TYPE OF INSTALLATION AND SPECIFICATIONS: A ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------------------- Material__-__________ ❑ No. of core;partments--------------------------Size--------------------------------Liquid depth------------------------ -Ca acit Disposal Field: Distance from nearest well____ _________Distance from foundation--------------------Distance to nearest lot line__________..----� ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench--------------'-----'- -- - --------- ype or filter material_________________________Depth of filter material--------_--------------Total length-_____.-..___--_____________-- Seepag it: Distance to nearest well-------- --------------Distance from oun ation_--____ __ �d_____-Di/stan�rp to nearest lot line____c3+ _.-- Number of pits- -- -- ----------Lining material_d_e._ -- --' .Size: Diameter------l-v�- Depth__.., --------------------- Cesspool: Distance from nearest well____--___^--___Distar:ce`from foundation------------------- maferilal------------------------------------- 0 _ Size: Diameter--------------------------------------Depth---- ` �------ -----------Liquid Capacity' gals. Privy: Distance from nearest yrell____________________ _)-A------------.-Dist nce from nearest building -------------------------- --- ❑ Distance to nearest lot line___________________________ ____ - Remodeling and/or repairing (describe):________ _ ________._ -�x - ---------------------------------------•-- s1� ;--y,�I- ;------ -- ,.moi:-�#:�Il-------- i . _ � i. -------------------•---•-----------------------•------------------- - -- -------.34 j j --'-----'-------•------------------------- --•-------------------- -------•-------------------------------- ---------- ------------- --------- ------------------ ------------------------------------------------------•----.-----•------•---, - ----------- -------- '------E--{-- I hereby certify that I have prepared this application and that +he work w1l the done iii accordance wifh San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin LocafAe'Afh District. (Signed)---- -------------- - 1 ________------•wwer and/or Contractor) r.1 gY� I (Title)----- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc.,!can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�--------' -- -------------------- DATE_ - REVIEWED BY - ------- --------------- ----- ------- _kDATE--- = UILDlNG PERMIT ISSUED_____________ " '" •"'-'� --------------------- DATE---- ' '�: Alterations and/or recommendations: -------------------------------- --� ------ ' •-----•--- -- •--------•--------•---•--------------------'----•---- - ------------------ _N- ----- -------- ---•----------- - -- --- --------------- _ r --...- _----- - -- ----- --t--- e •----------------_------_-- - �- r__ ---------- --- --- ------ --------- -------------------- --------------------- ------------------------------- --------------- -------------------------- - ---------- - -------------------- _- ._-__.____________ _______________- .._._________...______._._.._ ---------------------- •---FINAL INSPECTION BY:._____. r ( � + -------------------------------------- , 'Date iii i - ------ ----- ----- ----------------'---- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Americen Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 10.52 Revised W-2100 !