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APPLICATION FOR SANITATION PERMIT Permit No. ...�..... :..... (Complete in Duplicate) Date Issued ._.. ,j 1 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 JOB ADDRESS AND ON = . .•-• ------• . . `...... ----- ' Owner's Name------ ------------- -• _ ------ P� . Phone._-?--/--`��--- 7�-- ----- - ----------- ------------ - - -- ------------ -------------------- ---- Address------ ..... •-----••• ... -- .. -----•--• . . -----••--------•--•-•--•-----•-----•----------•--•------•------•-----•----•-•-•--••-••------•-•---••-••----•------•-••-••-•---•. Contractor's Name------------ •----- -- ---=-----n--------------------------------------------------------------------- Phone--- Installation will serve: Residence' Apa ment House,❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /_-_ Number of bedrooms ./--_ Number of baths _/-_-_ Lot size -/0©.X- �'-�•�.P 1 Water Supply: Public system Community system ❑ ,Private ❑ Depth to Water Tableft. /&OX � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobojl� Hardpan ❑ Previous Application Mader Yes ❑ No ' New Construction: Yes_P�r No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_��__--_-Distance from foundation_____s Mat^er�'' .----- No. of compartments-----..________. .__Size__ ._ ac .FLiquid depth__ _` -3_:__---Capacity..... 01 _a__ Dis osal Field: Distance from nearest well 5P_____ _Distance from foundation_____-1,0 Driolistance to nearest lot. line................. Number of lines----------------/____t-. -:______Length of each line__..._.... ._..=.Width,of french___......._X1------_ ��111 - Type of filter material________-�___a.____--Depth of filter material___`7$�..._: Total length_-__-_-----�0--------------------- _ - -------- 'f S epa Pit: Distance to nearest well _,l-/.2.11 (3rstancc _ st I t line..-... 7 Number._af.pits- Lining, material -- ._. . Cesspool: Distance fro-m' nearest well----------------- D,istance from foundation---------.----------Lining material-------------------------------------- ❑ Size: Diameter--------------------------------- ---Depth----------------------•- -- --- ---- ---------Liquid Capacity ------- _--gals. q Privy: Distance from nearest well---._- ----------------------a----- ------------Distance from nearest building------------------------------------------- Distance ___-__-----_._._-.-____---__-_ ---_•-.Distance to nearest lot l=ine------------------------ Remodel inci,.ped/or ------- -----• • -Remodelinci,.ped/or repairing (describe):...__f ___ -.z_-� ---- 1 --------------------------------------------------------------------------••--- ----------------------------------------------------------------------------------------------------------------------_------------------- 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 regu tions of the San Joaquin Local Health District. (Signed)-_..-.._ --------------------- ----��j��?�� ' j--,:- - - - •-- ------------------------ -------------------------------------- --(Own a /or Contractor) 1 = l 4) = ----------------- "Z(Plot plan, showi�lg s o o , location of system in relation to wells, buildings, etc., can be ed on revise s' e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------_----------- { ------------•------•----- ------ DATE---------- fl ✓G+� REVIEWED BY ----------------------------------------------------------- DATE---=---------........... BUILDING PERMIT ISSUED...............�f ...... DATE...._...._..__... ---------------------------------------------------------------- ---------- Alterations a d/or recommendations:........Q-Q- ---- ---- -. y .. -- ala.�. ------------------------------------ ----- - - ------------ ----------------------------------- ---------------------------- --------------------- ---------------------------------------------------------- ---------------------------------- -----------------------.------------------------------------------------------------------------- 4 A FINAL INSPECTION BY-------------- r- --------_----- Date--------------- -I------- SAN -vSAN 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 0 yy.