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.�-:-�--------- APPLICATION FOR SANITATION PERMIT Permit No4# (� (Complete in Duplicate) Date Issued-- -,�----F _ "3 Application is hereby made to the San Joaquin Local Hdealth DiNoc for o a permit to construct and install the work h ein described. This application is made in compliance with County Ornance q ,rr ------------ JOB ADDRESS AND LOCATION_opI - - ---------------------- ---. Phone------------------------------------ ---------------------- Owner's Name__-_-_-_-_-_--_.____ , - "do-11� ---------------------- r t.6 0r Address------------------------------- P hone----------------------------------- --------------------------------------------------------- ---------------------------------------- Other Contractor's ame______________•_--__-__--___ Motel ❑ ❑ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ J �� __ Number of baths _1____ Lot size _____ ______ Number of living units: __�___ Number of bedrooms _f__ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ❑ Clay ft. ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand C] Gravel 171 Sandy Loam 171Y Loam Previous Application Made: Yes ❑ No N New Construction: Yes a No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public;ewer is available within 200 feet.)/ Mat r' I_____!i_�__ �'' Septic Tank: Distance from nearest well--- Distance fro f nd i� ........ - . Ca acit orojo------- No. of compartments-.__._----?--__---------Size----- ��*y,'►riquid d`pth______�---------- p Y nce ine Disposal Field: Distance from nearest well--- Q___._Distance from foundation_-/��_--.----Width ofttrench est I I /-_.�--_------� ® Number of lines_______2------------ ------- -Length of each line------ - - f, Type of filter material-----r�--'- Depth of filter material _,_k Total length �^-� Seepage Pit: Distance to nearest well-----:_-Linin material Distance from foundation--iameter_- Distance toDnearest lot line---___--------- -ill�l ❑ Number of pits________________ g from foundation Cesspool: Distance from nearest well______________ Distance n_-_._-__.__.------- Lining material Ca it gals. F1size: Diameter--------------------------------------Depth--------------------------------------------- - --- q PacY--------------------------- Distance from nearest well_________________________________________________Di --------------------------------------------- stance from nearest building----------------------------------------- ❑ Distance to nearest lot line_____________________---------------- ---- ----------------•-------------- -- - Remodeling and/or repairing (describe):---------------------------------------------- ------------- --------------•-----------------------------------------•- - -----•-------------- ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with $an Joaquin County ordinances. State laws, and rules and regulations of the San Joaquin Local Health District. Sc ned ' --------- ---- ------------------------------------------------------------------------ _-(Owner and/or Contractor) (Signed) (42 - -------- - --------------------------- ---------------------- By: ----------------- Title ----------------- --------------------------------------------- - ----------------- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPA ENT E ON DATE----------- -- . - APPLICATION ACCEPTED BY----------- -_ s REVIEWED BY----------------------------------------------------------- ------------------------------------------------------- DATE •-------------•------------------- --------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------- ---------------------------- Alterations and/or recommendations------------------- ---------_----------------------- --------------------------------------- -•---- / ----------- ------- ------ ------------------------------------------------------------------ - - r--------'y------------ -------------------------------------- - ---------- - FINAL INSPECTION BY--------------------------------------------- Date------------------- ----------------- -------------------- ------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteea, California Y' cc—o—')M 10-52 Revised W-2100