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APPLICATION FOR SANITATION PERMIT Permit No. a ---lA-_-0-�--- (Complete in Duplicate) - - date issued Applica+ion 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 LOCATI ---�N_ -4J---- --- �.. �L/" JQI-.2 ----r -------------------- Owner's Na a-------, 1' ,�� C� � ---------------------------------- ---- ------ Phon Address_��/2a--------- 11- ------ -- ------ -f 'his fcl[ - j--I 91l�rx��rr�` Pxf l�r�n �.�! '`r..... Contractor's Name-------------------- �� ti c— Phone- 1 Installation will serve: -Residence jy Apartment House o mercial ❑ Trail Court ❑ Motel ElOther ❑ - _ Number of living units: _---- Number of bedrooms - --. Number of baths --- Lot size ----- ------------------- Water Supply: Public system ❑ Community system ❑ Private.9 Depth to Water TableJrvft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay aam ❑ Clay ❑ Adobe Hardpan ❑ W Previous Application Made: Yes ❑ No' New Construction: Yes ❑ 'No ❑ (,i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -Lg-ptic,.T ) Distance from nearest well-----------------Distance from foundation--------------------Material--------------------------------.--___---------. No. of compartments------------------ / --Size-------------------------------.Liquid depth--------------------------Capacity-_.------------------ Disposal Field: Distance from nearest well,46__--_Distance from foundation.-__- -.Distance to nearest lot line----, d Number of lines_--I---_--------t.--it--_��''}}-��_-_Length of each --------------Width of trench. r ''lillk - T e of filter material - 0 - De th of filter material----- �� Total len th----------------- ----0 ------__---- ------------------ Yp p � g Se epa e Pit: Distance to nearest well �1Q___--Distant fr Ifo dation---...a-.=_-_---Distance to nearest lot in 1-D "4 t Number.of pits..-.--,--------------Lining material_��/� -Size: Diameter--�-a�_"�.--__Depth---_--- ----�-----.-----_-- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------- ---------------------------- El _---- --------------_----_--_---_-_- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------- ----------------------------------Distance from nearest building--------_.-------__-----__---_-_._----. ❑ Distance to nearest lot lire----------------------------------------------------------------------------------------------------•---------------------------- Remodelingand/or repairing (describe):--------------------------------------- -----------------------------•-------------------------------------•-----------•------••-------------------•--- -------•---•--------- ------------- -----------------------•--------------------------------------------------------------------------------------------------- --------------------------- ------------------------------ I her y certify that have prepared this vplica+ion and that the work will be done in accordance with San Joaquin County ordinances, nd rul�s a regulationh► of the San J uin Local Health District. ---- (Signed �J+ -------------- --- ----- ----- �_ r Contractor) -- ) �� BY:----- -------------•......----------------------------------------------------------- -- (Title) ,gL U (Plot plan, showing size of lot, location of system in relation ells, buildings, e+ can be placed on reverse side). FOR DEPARTMENT,USE ONLY APPLICATION ACCEPTED BY�.-.- --- . DATE-- - REVIEWEDBY --- ------------------------- ---- - ------- ------------------------------------- DATE- �-- ---------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------------- --------- DATE--------------------------- Alterations and/or recommendations:-------------- -------------•------- ---------------------••----------•-------------------•---------------------•----•--------------- -------•---------------------•---•----------------------•-•------•--•------•------------------------------------------------------.-......---------------------------------------------------•-----------------------...---... --------------------------------------•------------------------------------------------------------•---•----------------------------------•--•----- --••--------•---------------------------------•-•-------•---•-----------•- ._..... •....-------•-•---------•-•----------•--------•----------•----•--------------------------------------------- -----------------------------------------------•-----------•-•-------- -------------------------------- f FINAL INSPECTION BY: 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-4-2M i ' Revised W-2100 i •