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EPermit No.�. ---- ' APPLICATION FOR SANITATION PERMIT (0,ornpleA in Duplicate) Date Issued Uj Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. A This application is made in compliance with County Ordinance No. 54?. ,� /r .# .l -------•----- -�----'•------•-•---'----------------------------------------------- 17d_?---�.V----`---------- �------ JOB ADDRESS A LXyt TION__ _ phone ea - - - i Owner's Name___. --`---- - - �-.p� Address - f�/1� �� , - ----------------------------------"------•----------"----•-----------"-----------•---`----------- --�--"---------------- Phone- = Contractor's Name___ Commercial Trailer Court ❑ Motel ❑ Other El Installation will serve: Residence �partment House ❑ ❑ �� ' Number of living units: _1_--- Number of bedrooms . Number of baths ._. -. Lot size -�"0----- - Water Supply: Public system Community system ❑`Private ❑ Depth to Wader Table p Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam ElClay Loam ❑ Clay E] Adobe ardpan ❑ ! Previous Application Made: Yes ❑ No �IVew Construction: Yes ❑ No 6-_ 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 from foundatiLn------------------- Liquid u'� �e th__Material--_-- -_Capacity_________ No. of compartments---------------------------Size.----••--------- q p } Disposal Field: Distance from nearest welt ----------------Distance from foundation-------.__.-----.---Distance to nearest lot line----------------- Number of lines---------------------------------Length of each line- ----------------------------Width of trench--------------------------- ------- Type of filter material-_-------`---------------Depth of filter material------------------------Total length--------------------------------- --,---- Distance from foundation-___- `.----Distance to nearest lot line__."- -"------ Seepage Pit: Distance to nearest well_ ------ p Number of pits----- -,/-------------- material"r'�,^.� u�",.Size: Diameter s De to �+2.�- --_ - �.. --ten: . -p—. y . Cesspool: Distance from nearest well_"_��°"�'_"""Distance from foundation_,..____.-__._____ Lining material_____....-._____________________ __. ----Depth----------------------------- ---------------------Liquid'Ca acct -----�--F-------- 11 ------gals:. ❑ Size: Diameter.-------�=--------- "----�� - Privy: Distance from nearest well._..___,_____--------------------- -- _____--____Distance from nearest building_________________________________________ . -------------------- - ❑ ----------------------------- Distance to nearestlotof me__"__._:`_______________ __ i Remodeling and/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. ` dos Contractor (Signed)-- ---- = --------------------------------------------------------------(Title)-------------- ------------------------------- ------- -------- By:_ (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 APPLICATIONACCEPTED BY---- ------------- --------- ------- ----------------- ------ --------- ----------- --------- DATE_� ------------------------------------------------- REVIEWED BY ---- ---- - ---- ---- --------------------- DATE----- — -------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------- :" ---' DATE--------- =------------------ • = ' --&-----------------`-------------------------- �` - Alterations and�or recommendations: -- --`---�-�4----lzuf--- � _ "- L ,___ _ ,� ----�---- -- Ae �e � ". _a --------------- -- t ' • s� + = � -------------------- 4 ._ ------ Date--------- fJJJ FINAL INSPECTION BY:___-- -----_�--------------�r. --- - - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 81.4 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California ri t5—q-2M 10-52Revsse'd