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1 APPLICATION FOR SANITATION PERMIT Permit No. ___: - ...---T (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 herei ascribed. This application is made in compliance with County Ordinanc No. 54?. f 1 JOB ADDRESS AND LOCATION_____- ---- _41;," ( -------- ----------•---------------- ----•------------------- Owner's Name_ " -- - -- -.�--------------------------------- - - -- --------------- Phone---- �� "7-,/ Address-----_-------- •------------ - --- - ------ -------------------- ---------------------------------- -?1 { Contractor's Name___________________________ ? ------ Phone.---- Installation will serve: Residence Apartment Hous Commercial ❑ Trailer Court ❑ Motel [IOther ❑ Number of living units: __/__- Number of bedrooms Number of baths -__- Lot size -----. ------------------------- Water Supply: Public systemx Community system ❑ Private ❑ Depth to Water Tabled_ ft. Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam Clay Loam El Clay ❑ Adobe Hardpan El Previous Application Made: Yes ❑ No)( 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 foundation--_Q-------Material------------------------------------------------- tic Tank:_ Distance from nearest well -- jy No. of copartments------ ------------------Size----------------------------• Liquid de h______________________ ___Capauty__.____.________ __.___ / ' Disposal Field Distance from nearest _ well------ from foundation________.__.__-____.Distance to nearest lot line_________-_ }}-� Number of lines---•-------------------------------Length of each line------------------------------Width of trench------.--------------------------- 4 � Type of filter material-------------------------Depth of filter material---------------------.Total length--------•----------------------------`--- Seepage Pit: Distance to nearest well_ ---Distance fr m fou anon--- ----___..Distance to nearest lot iine_e_.1+__-_-- Size: Diameter Depth---.. C0---------- ----- Number of its_ -.___ I__ Lining material_ -_ p { --- - Cesspool: Distance from nearest well----_------------Distance from foundation------------------- material___________._____.__.__-_._._____--s ----De th---------------------------------------------------Liquid Capacity- ------------------ - gals. ❑ Size: Qiameter------------ --- ------ -��- p ---------------------___---Distance from nearest building Privy: Distance from nearest ��+e4L------------ -- � g -------- ------------------------------- ------------------- Distance --------------------- ---- Distance to nearest lot ine_______ - --- -- ------------------------ ------ —`-' Remodeling and/or repairing (describe):_______.___-_ ___ ------------ --------------------------------------- ------------------------------•------------------- -- --------------- -------------------------------------------..---------------- )plication I hereby certify that 4 have prepared this aon and that the work will be done in accordance with San Joaquin County > ordinances, State laws, and rules arlregula ' ns of t San Joaqu' oval Health District. (q . ----_. __(Owner andl�or ntractor�` - Si nede__a, --'-- ---- - --- -................ - --- ---------------------------- ---------------(Title)- ----- --------1----r----- ----- ------- l By: (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p d on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATES, ------------------------------ --•----------------------•------------- REVIEWED BY_ -- --- DATE_. ' BUILDING PERMIT ISSUED------------------------ DATE-------„4-------------------------------------------------- ----------- Alterations and/or recommendations-------------------------------- --- ---------- ----------- -----------••---------------•---------------------------• ----------- QY ------------- FINAL INSPECTION BY:---------- .V____`-•--- ��_/!-G`-7---- --------- Date._.. ��'-'.�_�'_._rs�--�----�---------- -------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oat; Street 132 Sycamore Street 814 North "C” Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y. r ES-9-2M 10-52 Revised W-2100