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APPLICATION FOR SANITATION PERMIT Permit No.' .___... Il! (Complete in Duplicate)' Date Issued - _- - __---- Applica+ion is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County a No. 5 9. - JOB ADDRESS AND LOC ION---- 0 ---- ------- ---- ----------------------------------------------------•---------------- Owner's Name------Q--- --- ------- -•---------- •----- ----------- Phone Address (� 46 e .�.__.._..I...•- - .............._ - -- ------------ ................------ ----- •------- ----- -------- . -•--•-------••-----------•--•- Contractor's Name____ � _ _. - -----. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /----- Number of bedrooms __07- Number of baths I_.__ Lot size.__,SD ------Y./_d_@ _•-- _---_-___ - Water Supply: Public system I? Community system ❑ Private ❑ Depth to Water Table L/ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ 'Clay Loam ❑ Clay ❑ Adobe Eg Hardpan ❑ Previous Application Made: Yes ❑ No New`Construction: Ydro No'❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is-available within 200 feet.) Se f ank: Distance from nearest well________________Clistance from"foundation_____________..___..Material_ No. of compartments----- --_. Size -------------------------...Liquid depth--------------------------Capacity -------_--_- Disposal ield: Distance from nearestt ,well'WOP istance from foundation___Jp Distance to nearest lot line ........... rVr -Number of lines:_ __. _____ -'Length of each line_.__ ' __ Width of trench -r/ ' __--____ -Type of filter mate ria l_Sf J Depth of filter'material_ Total length---l-'. --•--- Seepage Pit: Distance to nearest well__40_W Distance from foundation-JA._____.__.Distance to nearest lot line__ ......... Number of pits_'._ A----------Lining mate ria llY_ttnctt.......Size: Diameter....4�G.............Dept h-----A-S------------------- (� Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material--------------_------_................ J ❑ Size: Diameter--- ------Depth------ ---------------------------------------------Liquid"Capacity------------- -----.gals, Privy: Distance from 4earest.well------------------------------------------------_Distance from nearest building_________________________________________. ❑ Distance to nearest lot line----- ----------------------------------------- ------------------ ------ -------- ............................ Remodeling and/or repair* g (describe):--- ,_.r------ ------... _ .__ _.__ oma__ _R______ - __________ _________ _ _-._. _ -_ f-- -_ , G�'�r ae" ---------------- ___ _................................................ ---------_----------------------------_----------------------------------------------------------------------------------------_------------------------------------------____________________________________-_______________ 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 Joaqui n Loc9l Health District. (Signed)------- •--- ---•---/ -- ---- -- - --------------- ------------- ----- - ---#---------- -- -( ner and/or Contractor By:------------��` -'�4 (Title -- -------------- ----- ---------------- (Plot plan, showing size of lot,location of s em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _..__- DATE -, REVIEWED BY--------------- DATE --- .. . BUILDING PERMIT ISSUED...................................................................................................... DATE............................................................. Alterationsand/or recommendations:----------------------------------------------------------------------------•---------------------'-----------------•---•-----•------........................ -------------------------------------------------------------------------------------------------------------------•----------------------------------------------------•----------------•---•-----.....-------...----------- --------------------------------------------------------------------------------------------------------------- -----------------•-----------------•---------------------•-------___----------------------------- ........ FINAL INSPECTION BY:------------------"--__ - ✓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-9-2M Revised W-2100