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APPLICATION FOR SANITATION PERMIT Permit No.31.6" ------------ in Duplicate)(Complete p } Date Issu "" ed -! .S-3 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 5 JOB ADDRESS AND%L'6CATION._ ------- --- ----- ---------------------- ---------- / . -1/1l1�-- -- - -`-�- _ .t ' ' ----.-. Phone---+�Y-�-------- Owner s Name"""_-_�::_"._ ------ '---- Address-----_----------------- Contractor's ---•-------•- -------- r�. �.. ------Q5,_• --- ------•---� - ----------------------- u Phone__'?._" �� ----- Contractor's Name""------------------••---'-_1-!-�--� �.L"�--1_t=-- --------"�-��----------------------------------------------- Installation will server Residence Apartment House mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units:- """" Number of bedrooms umber of baths _ Lot size . _ - - - ----- Water Supply: Public system (r Community system ❑ rivate ❑ Depth to Wafter Tables`ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam El Clay C] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 9, New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well, ^ -s"Distance from foundation------------------Material----- ..--_. _-- _ "" """"__. Septic Tank:, n No. of compartments--------�---------Size__ " -----------Liquid depth----s -------------Capacity.r�PQ-- ----- Disposal --_- "/ I p �I fi!f-.Distance from foundatiori___:�_--.-:.-__--Distance to nearest lot line--Z.-" Width of trench 4-`------------------ d Dis osal Field, Nlumber of lines ear0we, ""-" --------Length of each line--7- --`- p_ , Type of Filter material/I9!-��GJ°�"""De th of filter materia!"""" .......... p ' Total length---'f --------------------- NY Seepage Pit: Distance fornearest well----------------------Distance from foundation--------------- "Distance to nearest lot line--_-----_-_...- I ❑ Number of pits_-'-'---------""----Lining material-----------------------Size: Diameter-------,-------------- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material-------------------------------------- El ----.--------------- ._-___ ❑ Size: Diameter------------------ --------------------Dept h------------- -------------- -"-"--Liquid Capacity-------------------------- gals. a s. i Privy: '� Distance from nearest well----------------------_-.-._--------------------Distance from, nearest buiiding-____-----.---------_---------.-..._------ , -------------- ❑ Distance to nearest lot line- ------ --------------------------- ------------------------------------------------ Rem ng and/or,r airin escribe):_ ------- -,�-�- -......-�-------,/5---------_.1 ---fir--- ------ --- --- ----- ---- - ------- ---------- -- -- ------- ---- ----- ----- --- ----- -------------- ------ I hereby ter}i a repared this application and that .•he work will be do�a in accordance with San Joaquin County i ordinances, a la s, and r and r ulations of the San Joaq-Sn Local Health District. -- - - - - ------------ ner d C�c or) - - ---------------- - '--- -- -- - -- c;;....... {Title)------ --•.:_.z -- --- - - - -- -------------- (Plot plan, showing size of lot, Iota�ionof system in relation tow ll , buildings, a+c., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- -------- = DATE' 1 �— '""' ff // - ------ REVIEWED.BY------------------- -----' -- ' -----[� �./— ----------- DATE. `-- BUILDINGPERMIT,ISSUED--•----------------------------- --------------------------- --------- DATE----------------------------------------------------------- Alterations and/or recommendations------------------------------ --------•--------------------•-------------------------------------------------------------- ------ ------•------ ----------------------------------------------------------------------------- s '� ----------------:------•--- ----------------------------------------------- ---------------- ----------------------------------------' --- ----- --- -_-•------------ --------- ---------------------------------- ----------' L . y3 FINAL INSPECTION BY:. -' f�7 Date.... �------ 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-9-21v1 IC-52 Revised W-2100 '