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APPLICATION FOR SANITATION PERMIT Permit No. 1.4.7_..._._.:.3 (Complete in Duplicate) Date Issued ._�`._.�15�. Application is hereby ade 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. 5 JOB ADDRESS AND LOCATION ----------------- Owner's Name ------ Phone-- - �-- Address -- -------------------------------------------------------------------------••--------------------------------•------. Contractor's Name----=---- ------------------------------------------------------------------- --------------------------------- Phone = Installation will serve: Residence Ui Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1_--_ Number of bedrooms-A... Number of baths I.._. Lot size --......v!�a'�-�Y_ --------- ----------------------- Water Supply: Public system ❑ Community system ❑ Private [7�Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe zirdpan ❑ Previous Application Made: Yes ❑ No [��New Construction: Yes [�o❑ TYPE OF INSTALLATION AND SPECIFICATIONS:_ - - (No septic tank or cesspool permitted if pudic sewer is available within 200 feet.) / Septic Tank: Distance from nearest well�� Distance from f undation _. ._____ �vl�terial__11___ ____ _____ _.... No. of compartments-----X.---------------Size..YX_�f' -.)e_lt.--___,___Liquiddepth__aa_-/.j---------------- Capacity. --_d-`.__---.- W •�r Disposal Field: Distance from nearest well-.�'�5-��..-._Distance from foundatic2,n..q`0Distance to nearest lot line... ........... w g �U ¢G J� - 2 Number of lines----- --------_______ _ Length of each line ________ �_� Width of trench____..' �________.__..___._..._. NJ Type of filter material_- _...-_:Depth of filter maferial___� _______________Total length___1_ ....................... _n Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line-------.--------- w ❑ Number of pits------ ---------------Lining material--------------_------Size: Diameter------------------ ----Depth------ -------------------------- (( ,�, ' Cesspool: Distance from nearest well-_____-------__Distance from foundation._____---_---.__--.Lining material-_._______________________________ V1 ❑ Size: Diameter------------------------------------Depth-----------------•----------------------------------Liquid Capacity--------••------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------._-______-_-_________--__.__.-_--.-. ❑ Distance to nearest lot line------ -----------------•---•-----------------------•------------••---------------•----------------------•----•----------------------•------- Remodelingand/or repairing (describe):------------------------------------------------...........................= -----•-----'................-----•---------•-----•-----•--•••...-------•-- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------4------------------------------------------------------------------------------------------------------- 1 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 the San Joaquin Local Health District. (Signed)---- ------------------- ------------ --------- -- ---- --- ---------------- -------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------- .....--------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ DATE.. j REVIEWEDBY-------------------------------- ------- DATE-/"-'<--- - , ----------•--------------- BUILDINGPERMIT ISSUED---------------- ------------------------------------------------------------------- DATE Alterationsand/or recommendations:---------------------------------------------------------------------------•------------------------------------------•----------------------•---------------.- ---------------------------------------------------•-------------------..-----------------...------------------------------------------------------------------•------------------------------------------------------------ -------------------•-•-•---------------------------------------------------------- -------------------------------------•-----------------------•-------------•------------------------------------- •-------------------- FINALINSPECTION BY:.------- -t--- -------------- 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 0-52 Revised W-2100