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- APPLICATION FOR SANITATION PERMIT Permit N 0o. � f� (Complete in Dupl' ate) A�� 1ri i 'Ae.�m �a I!�� '.��'"2-� Ra�+f7'eM, Date Issued ---/��'-1---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install t e work herein described. This application is made in cpjnpli nice with County Ordinance No. 54 JOB ADDRESS AN LOC ION. . Owner's Z Addess-_Name-------- - C K....... ------`------- CL ----------------------------- Phone.... Contractor's Name--- ------------------- ------------------------------------ •---- •------- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ •Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_ .__ ber of bedrooms .3_ Number of baths!-/---- Lot size ----a._5- --- Water Supply: Public system` Community system ❑ Private ❑ Depth to Water Table ________ ft. , Character of soil to a depth of 3 feet: Sand [ �_ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ardpan ❑ l Previous Application Made: Yes ❑ No-21-11"New Construction: Yes No ❑ FHA/VA: Yes ❑ No ) TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer-is available within 200 fe t.) Septic T Distance from nearest well__ -_Distant from oundaion___ __ ________Mytt ris31______-_-_____---------:------------------- No: __________-_____- - �." Liquid de�th Ca aci Q No: of compartments------ --- ---- ---Size q P tY Dispos field: Distance from nearest well_N��.__Distance from foundationN ---------------Distance to nearest lot line 17 - ---- __ - Number of lines-------- _______________ ____ Length .oT'each line........ -----------Width of trdnch--- - `--- } 4 Type of filter material_ ___ _Depth of filter material____ > Total length--- --------------------- � Seepage Pit:, Distance to Weare well_ ----_-------------Distancejrom foundation-----------.---------Distance to nearest lot line------------------- ❑ Number of pits-. Lining material-----------------------Size: Diameter------------------------Depth-_----------------------- ----- p � Cesspool• Distance from nearest well____________---Distance from foundation--------------------Lining material__-_________--_____________._________- Ma. ❑ Size: Diameter Depth ----------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____ ______________Distance from nearest building--- ------------------_ ,_,____._. ❑ Distance to nearest lot line--- --------------------- --------------------------------------------------=------------------ kk i Remodeling and/or repairing (describe):-------------------------------------== ~'--------------------------••---------------------- ----•--------------- - --- .----------•------------------------------•----•----------------------------••-------------------------------------- ------------------------------------- ----------------------•-------------------------------------- ' ' -------------------- -------------------------------------------------------------------------------------•-----------------------------------------------•--------------------------------------------------------------- 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 a d regulations of the San Joaquin Local Health District. (Signed) ' ----- ----------- - ------------------------------------------------------------------- ----------------------------(Owner and/or Contractor) 1 "'NBy=--------------- ----------------------'----------------------------------------------------------------------------(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 i APPLICATION ACCEPTED BY------------------ --------- ----- ------4------------------------------------------------------ DATE------------------------------------ '} REVIEWEDBY-------------------------------------- - - - -- ------------------------------------ ------ DATE------------ BUILDING PERMIT ISSUED --------=----------------------------- DATE-.----- Alterations and/or recommendations:--- --- ----------------- ------------------ --------------------------------------------------------------------------------------------------------------- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- -------------------------------------------- ---------------------------------------------------------------------------- FINAL INSPECTION BY:.--- ;,. ------ Date ------------ --------- r. 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 , Revises 1.57 F.P.00.