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APPLICATION FOR SANITATION PERMIT Permit No. _._.._ _?�_-.!__ N� _ -. k R , {Compleie in Duplicate a Date Issued ECpplication is hereby made to the Sats Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Or inance o. 9. - ---------------------------- ---- --- -••------------------ ------------•------------------------.....------------------------..._ ---------- JOB ADDRESS A LOCATION---- i Owner's Na ,e c r------------•----------------- Phone Address.---. A- �.� - -- - --•- ---- - ------- - --- - �c---=�-s-- �------------------------•-------------.....----•-••---- Contractor's Name. = ----------------------------------- ---i- - - -------------------------------------- Phone Installation will serve: Residence 0/ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f r �� Number of living units: __.[._ umb ;of bedrooms _,�t__ Number of baths p-�___ Lot size �_�__x__�_Q�--------------------------- Water Supply: Public system _Community system ❑ Pri'v e Depth . Waf& Table -------- ft. ' Character of soil to a depth of 3 feet: Sand Gravel ❑ SLoam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑' i Previous Application Made: Yes ❑ No New Construction: Yes No ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tan0or cesspool permitted if public sewer is available within 200 feetr) ` A I�,,��/ Septic Tank: Distance from neafesi welL_._-� °Distance fro `foun�latian_/ Mater'�L____ --.-__. _. ___ ._-- --- No` of compartments: .;_--- 1-_._----- -Size .} - _Lill depthr----- ---- -------------- apacitY----- - -- -- E ��jj� J Dispos Field: Distance from nearest well'f�Il_ Distance from foundation-_____ �_�_---. istance to nearest lot line _��-__ Number of lines----------�---- ---- "__-- Length of each line------------ - - Width of trench.___----Z_- //}} Type or filter materepth of filter material---_.---- ----- ----Total length_-- Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------?.___.Distance to nearest lot line-___-..__-___.__ Number.of pits----------------------Lining material-----------------------Size: Diameter------- ------------Depth---------------------------.--"-- t. �> 1 [ Ce s pool• Distance from nearest well----------------- from foundation__ .--------'___..1L'i�ing material_______"________-_________.________. ❑ Size: Diameter--------------------------- ` ----------Depth ------------------------------------------------Liquid Capacity----------------------------gals. . Privy: Distance from nearest welDistance from n -------------------------------------------------- earest building-_-_--.._________-- "_-..-----_______._. ❑ Distance to nearest lot line--------- ------------------------------------- -------------------------------------------------------------------------------------------- - Remodelingand/or repairing (describe):-------------------- --------------------------------- -----------------------•----------------•---------------I---•----------••------------------------ • ------------------- -------•---------------------------------------------I---------------------------------- ----------------------------=------- ------------------------------•------------------------------- " k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, ate law , ar�ct"rules and regulations of the San Joaquin Local Health Disfric .r.. •b - ; Owner and/or Contractor {Signed) ( / ) By: = ------------ ----- = T1tle ------------------- -----------------------( � )----------------------=---------------------------------------- �(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse'side).. OR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY-- ------- ------------------ _ _ = �--------------------- DATE.�f-`^---•--------t�'------------------------------- REVIEWEDBY---------- ----------------------- --- -------- ----__...__- -- - --------------------•------------------------ DATE------ - ------------------ -------------------------- BIJILDING PERMIT ISSUED--------------- --------- ---------- ------ - -------- -- ------------------• ATE � --- f - i Alterations and/or reco mend' s: .r/_1-0 '�a". (� '" 1 rt � __ --_"-__."_____________________"__._____- r _ _:�=�--�---------------------------- - -- - )_--�-_-------------_---------------------_- ........................ ------------ ----- -----------•--•----------- -------•--•----------------------------------•----------------------------------------------- " -�------------------------------------- ------------------------------------------------------ ---------- -------- 1 # I ------------------------- ----- ------ - - FINAL INSPECTION BY:.. Da a = _ -`------ "�-------------- -- - --------------- SAN JOAQUIN LOCAL`HEALTH DISTRICT 130 South American Street 300 West Oak Street--% 132 Sycamore Street $14 North "C" Street Stockton, California— —-Lodi,-California "` ""' Manteca, California— —Tracy,California E5-4-2M 10-52 Revised W-2100