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r `T „ APPLICATION FOR SANITATION PERMIT Permit No. . __._r .. r omplete in Duplicate) �/ ,�1C / Date Issued _1 .x' 5` Appl ca+ion is hereby made to the San J? in cal Healtlf�District for a pe two ycooisstir end i 11 work in dg ri ed. This application is made in compl'ian i dinance No. 5 � j- LOC JOB ADDRESS D ION - . _ -- ; .1 _--__ z_' __. '.r-------------- Owner's ame......... ••• ... • •-•••---,....... } Phone. Address------------•-•---- •---•-,C�.... . •--'---*F ------------------ -----� -'•-------•-•-•------•----••--••--•••--------•--••-----•-----------•--.-•-•-- Contractor's Name..-- •••.•. ------- -- -•••-•-•-_--•.-----------•_•------------------------------•----------------------------....---•--------•--. Phone_......................---------- Installation will serve: Residence// t Apartment House ❑ Commercial ❑ Trailer Court ❑ Motgl ❑ Othe ❑ `= Number of livirIg units:,-,L 'Number of bedrooms _-�"�.I Number of baths _I.... Lot size • .._ �Y. ............................ Water Supply: Public'system [Community system I] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel❑ Sandy Loam Clay Loam❑ Clay❑ Adobe�ardpan ❑ Previous Application Made: Yes E] Q No " New Construction: Yes Loam ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if4ublams. is available within 200 feet4 Septic ank: Distance from nearest well__-.._-_. a a from;ound t* n_1 n-10--- ..Mater l 64-__.- - No. of compartment4*4 Size. . - _Liquid depth ---- -�{-:_.-_-.__-Capacity...... Q .._ n ispos Field: Distance from nearel1stam;e from �oundationji .__-____-. istance ti Nearest to liNumber of lines-------- ---- -Length of eachline.....-__..--__. Width of trench.- ___._..._.. .Type of filter materiepth of filter matenal.-_.-_�- _ ___--__Total len Z.- _-�................. Seepage Pit.: Distance to nearest well---.------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits----------------------Lining material_.---------------------Size: Diambter---.._-_--.._.__-_---Depth-------._.-------.-.----------._. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size: Diameter--------------------------- ----------De th----------------------------- ❑ p ----------------------------------------------------Liquid Capacity----------------------------gals. . Privy: Distance from nearest well------------------------------------=------------Distance from nearest building------------------------------------------ r_1 Distance to nearest lot line---------------------------------- -------••--------------•---------•- Remodeling and/or repairing (describe):---------- ------- .....................................................v----•---- -----------•............................. ..................... =----------------------••-•--------------------•--------------------------•-------....-----•......-•••-•••-••-•_•---••......•---••......----•--- _ _- `--•-----•-------------------------------------------------------•---------------------------------------................................................................................................... ..................... ---•-•-----------------------••••-•----••-••----•-•-_••-•--------•-•--------•-----•••----•-•------•-•-_---•••...----------------------------------------------------------------•-•--- 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. r = (Owner and/or Contractor) (Signed - tt..IC.: .a• --- By:._..-•----•-••-----------•---••--••••--••---••••-••-••••--•-••••----•........................•-••-•-•----_----------___--•---•------(rtle)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONL APPLICATION ACCEPTEDBY -----------------------------------------•.-.-•------------------------------.- DATE ------------------------------------- REVIEWEDBY---------------_-- -------- ---- ------------------------------------ ---------------------------- DATE_- BUILDINGPERMIT ISSUED............ ---------------------------------------------------------------...................... DATE........k&.............................................. Alterations and/or recommendations: ---------------------------------------------•--------------------------•--------------•-......... -------------------------------------------------------------------------- - ..............................................................-- --------��,�•----r�_--- -� ....................'7` 6c� *r7`' Y�cc 410-�d --- ---- =-- --- - ------------------ --- -- 4 .m.'k .. __)_i ... c' FINAL INSPECTION BY:. ---- - ------ - ----------------- ------------------ Date..-.. SAN JOAQUIN LOCAL HEALTH DISTRI 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