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rfA APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) � ✓ Date Issued '___ G 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 No. 54 . JOB ADDRESS AND 7LOCATION______ _____� t - -=------------------ ' FOwner's Name-- I- -: ---- Phone Address-------- - ----------- -Z---------- , ---- --------------------------------------------------------------- - Contractor's Name `� I nr/71-- - ----- ------ Phone Installation will serve: Residence ZK`Xpartment House ❑ Commercial [] 'Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j-._ Number of bedrooms > . Number of baths _" "" Lot 'size __ ------------------------ Wafer Supply: Public system-ITKCImmunity system 0 Private ❑ Depth•to Water Table Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay E] Adobe 01/5ardpan ❑ Previous Application Made: Yes ❑ No ®fNew Construction: Yes ❑ No E 1=HA/VA: Yes ❑ "No Z4-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool`permitted if public sewer is available within 200 feet.) Septic Tank: Distance from,nearest well____. _Distance fr m foundation____ -/_ f 1 _4 No. of compartments____- ' Size__ /1_ ' / . . Liquid defy/th-----1-1 ---------Capacity---- Disposal Pi Distance from nearest-well___ ---- Distance from foundation__. �-1-_�-Distance to nearest lot line___" Number of lines-<,=_ Qength of each line_-______"- _ / 1i--- -- __ Wdth of trench----,. — --- Type of filter material.'_"�" - �/ i epth of�filter material::__ ___ �_"Total length_____._ "•-------/ ---------- Seepage Distance to nearest well ---""___-_...`Distance fr fou ation "s /-.Distance to nearest lot Number of pits-- hal liilnne__"",�.____._ '-_-_{ Lining. rateri _.__ Size: Diameter.._ / < <. _._ - - ��.--�---.Depth-----rte-- - ------------------ Cesspool: Distance from nearest well____" ------Distance from foundation___---------___-----Lining material_____._ _ Liquid Capacity ______.________._____._____.. ❑ Size: Diameter------ ------------------------------Depth------------------------------- ------ ---------gals. ' Privy: Distance from nearest well___________ _ ____: _____ __ _____._"Distance from nearest buildin ❑ Distance to nearest lot Line---------------- ' Remodeling and/or repairing (describe):____""__ _ - Q � f -------------------------------------------•-----•-----------------------------------•--------------- ------------ --- --- - --------------------------------------------------------------------------- I hereby certify that I have prepared this applicafion and that the work will be done in accordance with San Joaquin Count ordinances, State laws, a d rules and regulations of the San Joaquin ocal Health District. (Signed)------------ -J -- -- f - -- ------------------------------------------------ r Contractor) By:-- ------------------------• - - ---------------------------------------- Title----- (Piot plan, showing size of lot, loc n of system in.relation to wells, buildings, 9fc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- - ---- -------------------------------------- DATE---- REVIEWED BY-------------------------------------- -. -- -- ----•- -- -- - DATE---- -- --=--- -- --------------------- BUILDING PERMIT ISSUED_______________________" " "_"__ -------------- -------------------- -------- "------- ---- DATE Alteratio an /or recommendations:________ ---------------- ------------------ •-------------------••------------ --------------------------- ------ --------- ------------------------------------------------- -- FINAL INSPECTION BY:. --------------------•----- Date---- SAN JOAQUIN LOCAL HEALTH DISTRICT. 130 Soufh Amarican Streof 300 West Oak Street 132 Sycamore Sfree+, 1.s 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-21x1 , Revisea 1.57 F.P.co.