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APPLICATION FOR SANITATION PERMIT Permit No. .__.1 -�a------✓--- t� � (Complete in Duplicate)'" Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. —r This application is made in compliance with County Oirdinappee No. 54 , if #1 JOB ADDRESS D L T ATION . �° --- ---------•-----------------------•---------- __ __ _________�.. i - ---- --- Phone. --Phone Name ------ ...3►f - - - --- ,, 1 ------------ --------------------- Owner's Address ...... Address Name---- ------- ---- --- - ------------------------------•----------------------------------------------- -------------------------- -- Installation will serve: Residence Apartment House F1 Comm ❑ Trailer Court [I Mot Other ❑ Number of living units: __'---- Number of bedrooms _h-- Number aths __�____ Lot size ____ -------------------------- Public system Community system ❑ Private Depth to Water Table _._.._._ ft. Water Supply: Pub y ❑ ❑ y Adobe�ard an Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ClayLoam Clay ❑ P ❑ Previous Application Made: Yes ❑ No New Construction: Yes Loam ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sevrer i available within 200 feet.) Septic ank: Distance from nearest well__ .__ ---_--_-- ista a fro oun ipn__1.0---------..Mater I --------- ---- - -------- f - Li uid de th---------�---------Capacity---- -- No. of compartments__________ __ ___t___-- Siz X_-- ---x' q �+►/ �} istance from foundation______ ___ _____ is ance to nearest I I' a ---—_--.---• (n Dispos Field: Distance from nearest el_ 0!7' Width of trench------- ---- v' _ ---- -- --- Number of lines___________ ______ _______s___�_Length of each line______. __ nn , `� e th of filter material--------- _ ----- length �,l.L------------------ yr Type of filter materi _ --------- - P Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distahce to nearest lot line_-.__--___-__-___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------------------------Depth------------------------------- Cesspogl: Distance from nearest well-----------------Distance from foundation----------.--------.Lining material------------------------------------- ❑ Size: Diameter--------------------------------------Dep th--------------------------------------•-------------Liquid, Capacity----------------- ---------gals. Privy: Distance from nearest well-------------------------------------------------Distance 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 San Joaquin County ordinances, ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed]_ _ - ----------------------------------------------------------(Owner and/or Contractor) ------------ ------- - ----- 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- rb---------------------------------------------------- DATE-_% ----------- Alterations BY ---------- ---------------------------------------- ---- -- ---------- DATE--•----- ------------------------------------------------ BUILDINGPERMIT ISSUED--------------------------------------------- ------------------------ Alterations and/or recommendations:----------------------------_---------------------------------------------------------------------------------------------------------------------- --------------- ------------ -- ---- ------------------------------------------------------------------------------- -------------------------•- : ---, --- -----------�----------- ---------G s saw,abad � ,rb ---- r --d c - �" . ----------Y270-wh---------- ------ `-�------- ----- „�� ------------------- --dam► ---�----a t -- �i�?,7 5"<�1 Date le- FINAL FINAL INSPECTION BY_____________________________________ __ _ 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 I0-52 Revised W-2100