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i APPLICATION FOR SANITATION PERMIT Permit No. J r (Complete in Duplicate) Date Issued @ 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 LOCATION__ 5 - ----------------------------------------------- ----------------------------------------------------------------------------------------------- Owner's Name--------------------------------- --- ----- - ti------------------•----------------------------------------------------- Phone------------------------------------- ----- --- -- Address..........------------C.�� — -- -- - ----- ..r -- ------- --le------- -------- --: � = ---- ---------- Contractor's Name - 4-d __ ""` _10- # Phone - 4; Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - 'Iimber of bedreo`ms Number of baths o � f size __ _ 6 ! Water Supply: Public system Community system El -Private E] Depth Ac, Water Table_ ft. r Character of soil to a depth of 3 feet:` Sand ' Gravel ❑ Sanrdy Lo;��N, Clay Loam [-] Clay [j Adobe Hardpan'❑ r Previous Application Made: Yes El No [ New Construction:-'Yes ❑ h TYPE OF INSTALLATION AND SPECIFICATIONS: 'i av' (No septic tank or cesspool permitted if public ser 1s available within 240 feet.) IISeptic Tank: Distance from nearest well _--- stancefrom f undation_[_-Q___ _____.MateriaL 1 ---------------------- -------- - ii No. of com arfinents___- - _____- ize-- qdepth _ Li uid _ _, -----Capacity--------- Disposal Field: Distance from nearest weh/44 __Distance from foundation_/+:57__t------Distance to nearest lot�ine__ ► ___-__, Number of lines_____ Length of each lline_____e _____ Width of trench_____ --- -- CJ-�----------------- Type of filter material:_ _� __ __�___Depth of filter material____�-��^�_____:---Total length----------- :_ Seepage Pit: Distance to nearest well---------------------- from foundation-------------......Distance to nearest lot-line________________ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-------------------------Depth-------------------------_------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--________-___________________-______- ❑ Size: Diameter---------------------- ---- -----------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: -Distance from nearest well----------------------------------------- _______Distance from rnear&sf building------------------------------------------ ❑ Distance to nearest lot line------ - --- ----- ------ -•------------- Y - w , - O 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 an reg lations ofit a an Joaquin Local ealth District. F � Si ned �„� _ � �"` _ -__- �ernntractor ( g ---------- } i E t By:-------- - ---(Title) ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s r FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY----- ---------------------------=--- --------------------------------------------------------- DATE-- ` REVIEWED BY ------------- - DATE___- BUILDINGPERMIT ISSUED-------------- ----------------------------------- ------------------------------- ----------------- DATE------ --------------------------------------------- Alterations an or reco mendations- --- - ------------------------------------------------------------'e-------------------•------------------------- . h --- --' _ _�r_'" ' �*"---------------------------- --- -------------------------------------------------- ---------------------------------------------------------------------------=--------•------------------------------------------------------------------------------------•------------------------------------------------ - ------------------------------------------------------------------------------- ---- FINAL INSPECTION BY:------- ef. Date l Iyd filr- ' e k SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" S+reat Stockton, California Lodi, California Man+ena, California Tracy, California ES-9-2M 8-51 Revised W-2100